Forte, Brett Andrew and Maddison, Ricky Charles

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the deaths of Brett Andrew Forte and Ricky Charles Maddison TITLE OF COURT: Coroners Court

JURISDICTION: BRISBANE FILE NO(s): 2017/2232, 2017/2261 DELIVERED ON: 14 March 2023 DELIVERED AT: Brisbane HEARING DATE(s): 13 October 2020, 12-23 April 2021, 12 November 2021, written submissions July – September 2022.

FINDINGS OF: Terry Ryan, State Coroner CATCHWORDS: Coroners: inquest, domestic violence, shooting of police officer, siege, automatic rifle, police shooting of armed offender, adequacy of police investigations, incident command, police intelligence.

REPRESENTATION: Counsel Assisting: Ms Rhiannon Helsen Mrs Susan Forte: Mr David Funch, instructed by Howden Saggers

SC Nielsen: Mr Angelo Vernardos, FC Lawyers Commissioner of Police: Mr Michael Nicolson, instructed by QPS Legal Unit Snr Sgt Cooling, Snr Sgt Browne, Sgt Fitzpatrick, Sgt Douglas, SC Barlow, SC Smart: Mr Calvin Gnech, Gnech and Associates Police Negotiators, Toowoomba Tactical Crime Squad Officers, SERT Officers: Mr Troy Schmidt, instructed by Gilshenan and Luton Inspector Wright, Inspector Cumming: Mr Anthony Kimmins, instructed by McGuiness and Associates DSS Hinshelwood: Mr Adrian Braithwaite instructed by Queensland Police Union of Employees

Contents

INTRODUCTION

1. Senior Constable Brett Forte (SC Forte) worked for the Toowoomba Tactical Crime Squad (TCS) at the Toowoomba Police Station. His wife, Senior Constable Susan Forte, (Mrs Forte) was the dedicated Domestic Violence Project Officer attached to the Toowoomba Station. In early 2017, they were both engaged in efforts to protect the community by apprehending Ricky Maddison, a violent and dangerous domestic violence offender.

2. SC Forte died after he was shot by Ricky Maddison on a remote section of Wallers Road, Ringwood on the afternoon of 29 May 2017. After shooting SC Forte, Mr Maddison continued to fire rounds of automatic gunfire into the surrounding bushland, before retreating to the nearby shed where he had been living.

3. A siege commenced, and at around 5:00 pm on 29 May 2017, police started to negotiate with Mr Maddison. He was asked to surrender on no less than 85 occasions. Negotiators gave repeated assurances that he would be taken safely into police custody.1

4. During the siege, Mr Maddison fired at police at least 21 times. His last shots were fired at 11:05 am on 30 May 2017.2 Mr Maddison was then shot by SERT operators after he fired his automatic KS-30 rifle at Police and attempted to escape the inner cordon.3

INQUEST ISSUES

5. Following a Pre-Inquest Hearing on 13 October 2020, the following issues for the inquest were determined in relation to the death of SC Forte: i. Findings as required by s.45(2) of the Coroners Act 2003; namely the identity of the deceased person, when, where and how he died and the cause of his death.

ii. Examine the interaction between the QPS and Ricky Maddison in the lead up to the death, including the Gatton Police investigation into automatic gunfire at Wallers Road, Ringwood; iii. Examine the circumstances, which led to Senior Constable Brett Forte coming in to contact with Ricky Maddison on 29 May 2017, including previous attempts to locate him, as well as the decision and management of the pursuit and attempted apprehension of Ricky Maddison on 29 May 2017; iv. Consider the appropriateness of actions by the attending police officers on 29 May 2017 in relation to Ricky Maddison; v. Examine the Queensland Police Service response following the shooting of Senior Constable Brett Forte, including the provision of assistance and retrieval; vi. Consider the adequacy of the investigation into the death conducted by officers from the Queensland Police Service (QPS) Ethical Standards Command; and 1 Ex A7, pg. 6 2 Ex A7, pg. 6 3 Ex A7, pg. 6 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 1 of 82

vii. Whether any preventative changes to procedures or policies could reduce the likelihood of deaths occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice.

6. In relation to Mr Maddison, the following issues for inquest were determined: i. Findings as required by s.45(2) of the Coroners Act 2003; namely the identity of the deceased person, when, where and how he died and the cause of his death.

ii. Examine the interaction between the QPS and Ricky Maddison in the lead up to the death, including the Gatton Police investigation into Automatic Gunfire at Wallers Road, Ringwood; iii. Consider the appropriateness of actions by the attending police officers on 29 May 2017 in response to Ricky Maddison; iv. Examine the siege management strategies and negotiation processes employed, including the effectiveness of the negotiation processes; v. Examine the events that led to the decision by police to shoot Ricky Maddison; vi. Consider the adequacy of the investigation into the death conducted by officers from the Queensland Police Service (QPS) Ethical Standards Command; and vii. Whether any preventative changes to procedures or policies could reduce the likelihood of deaths occurring in similar circumstances or otherwise contribute to public health and safety or the administration of justice.

7. After I determined that the inquests into the death of SC Forte and Mr Maddison would be held together, the inquest was commenced in the Coroners Court at Toowoomba from 12 to 23 April 2021. Following the adjournment, a direction was given requiring submissions, prior to the resumption of the inquest, with respect to:

• The proposed witnesses to be called, including whether any additional witnesses should be added to the list and the basis for their inclusion.

• The scope of the inquest, including any additional or specific issues that parties submit should be considered as part of the inquiry.

• Further matters of relevance to the inquiry, including whether any further material should be sourced.

8. I ruled on those matters on 16 August 2021. A further day of evidence was heard in Brisbane on 12 November 2021. The inquest was then adjourned again to enable submissions to be filed in relation to a victim impact statement Susan Forte wished to read in the courtroom. After a ruling was given on that matter on 7 July 2022, submissions on the inquest issues were provided by counsel assisting and those given leave to appear at the inquest. I am grateful for the assistance provided by those submissions in the preparation of these findings.

Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 2 of 82

9. During the course of the coronial investigation, Mrs Forte participated in a number of interviews with ESC about SC Forte’s death and the preceding events in relation to Mr Maddison, including her role as the Domestic Violence Project Officer, Toowoomba Police Station.

10. By July 2018, Mrs Forte had outlined her concerns about SC Forte’s death in writing.

They can be summarised as follows:

• Police interactions with Mr Byatt on 18 May 2017 – Mrs Forte questioned why SC Thaler was near Mr Byatt’s residence on Wallers on this date. She was aware he had been tasked with finding Mr Maddison. She queried whether telephone records and text messages with other officers, Snr Sgt Stahlhut, Sgt Jenkins and Sgt Curtain were reviewed to see whether his account about why he was in that location was legitimate.

• Sgt Jenkins presence in Communications Room during the pursuit – Mrs Forte claimed she was aware that Sgt Jenkins was relaying information to Sgt Douglas about the need to apprehend Mr Maddison during the pursuit. This may have affected Sgt Douglas’ threat assessment and decision-making regarding continuation of the pursuit.

• Separation of officers after incident – Mrs Forte was advised that Sgt Curtain, Snr Sgt Stahlhut and SC Thaler were not separated prior to being interviewed by ESC with respect to the incident. It was alleged that there was significant communication between these officers prior to their respective interviews, which took place 14 days after the incident.

• Calls for service re: automatic gunfire in the Ringwood area – Mrs Forte raised concerns about whether these reports were adequately followed up with the informants interviewed.

• Delay in Gatton CIB investigating DV incident involving firearm – Mrs Forte alleged there was delay by Gatton CIB in investigating the DV complaint made by Ms B in March 2017.

• Threats made to kill Snr Sgt Stahlhut in 2007 – Mrs Forte claimed this threat may have influenced Snr Sgt Stahlhut’s desire to apprehend Mr Maddison.

• Recommendations regarding bail of violent offenders – Mrs Forte recommended that there be a full review of the judiciary and the granting of bail for extremely violent offenders. She also suggested that a circumstance of aggravation be included for all DV related offences.

11. Following submissions from other police officers represented at the inquest, Mrs Forte provided a further sworn statement during the inquest proceedings, at my direction. In addition to outlining further details of the above concerns, Mrs Forte also raised concern with the lack of sharing of information between TCS and TAT and the impact this may have had on officer safety.

Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 3 of 82

12. I note that the concerns of Mrs Forte and SC Nielsen about the conduct of other police officers, including Ethical Standards Command (ESC) investigators, during this inquest and in the investigation of her husband’s death were highlighted in A Call for Change, the November 2022 report of the Commission of Inquiry into Queensland Police Service responses to domestic and family violence.4

13. A Call for Change noted: “Many QPS members expressed disquiet and sorrow at the organisation’s treatment of Senior Constable Susan Forte and Senior Constable Catherine Nielsen, including in having complaints filed against them after raising their concerns at the inquest.

There is a view that the filing of complaints of this kind has only added to the culture of fear of speaking up in the organisation.”

14. In addition to highlighting significant cultural issues within the QPS, I note that the Commission of Inquiry found the QPS “conduct and complaints system was not sufficiently independent, effective, fair, accessible, responsive, transparent or timely;” and that it “did not always manage complaints about police conduct in an appropriate way or inspire community or police confidence in the Service.”

15. The Commission of Inquiry recommended the establishment of “a civilian control model” to ensure that complaints about police will be handled in an independent and effective manner. This recommendation has been accepted in principle by the Queensland Government and may see the creation of a Police Integrity Unit (PIU) within the Crime and Corruption Commission (CCC).

16. This is consistent with the recommendations of the Independent review into investigations of police-related deaths and domestic and family violence deaths in Queensland, which followed the Inquest into the death of Cindy Miller.5 The implementation of the recommendations from that review would see responsibility for the investigation of deaths in police custody or police operations shift (such as SC Forte’s) from the ESC to the CCC, under the direction of the State Coroner. The Queensland Government has not announced its response to these recommendations.

Coronial Jurisdiction

17. An inquest is a fact finding exercise and not a process for allocating blame. The procedure and rules of evidence used in criminal and civil trials are not adopted. “In an inquest there are no parties, there is no indictment, there is no prosecution, there is no defence, there is no trial, simply an attempt to establish the facts. It is an inquisitorial process, a process of investigation quite unlike a trial.”6

18. The primary purpose of an inquest is to inform the family and the public about the matters required by s 45 of the Coroners Act 2003, including how the person died and what caused the person to die. However, it is recognised that there are limits in terms of the remoteness of particular events in assessing causation. In Re Doogan; Ex parte Lucas-Smith7 it was held: 4 www.qpsdfvinquiry.qld.gov.au 5 Mazerolle et al, Independent review into investigations of police-related deaths and domestic and family violence deaths in Queensland, (Report, 12 July 2022) 6 R v South London Coroner, ex parte Thompson (1982)126 S.J. 625

7 [2005] ACTSC 74 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 4 of 82

19. A line must be drawn at some point beyond which, even if relevant, factors which come to light will be considered too remote from the event to be regarded as causative. The point where such a line is to be drawn must be determined not by the application of some concrete rule, but by what is described as the “common sense” test of causation affirmed by the High Court of Australia in March v E & MH Stramare Pty Ltd (1991) 171 CLR 506 ; 99 ALR 423 . The application of that test will obviously depend upon the circumstances of the case and, in the context of a coronial inquiry, it may be influenced by the limited scope of the inquiry which, as we have mentioned, does not extend to the resolution of collateral issues relating to compensation or the attribution of blame.

20. In the context of this inquest I have been mindful of hindsight bias. Hindsight bias refers to the tendency of those with knowledge of an outcome to overestimate the predictability of what actually occurred relative to alternative outcomes that may have seemed likely at the time of the event.

21. A coroner is prohibited from including in the findings or any comments or recommendations any statement that a person is, or may be, guilty of an offence or civilly liable.

22. The findings of a coroner must be based on proof of relevant facts on the balance of probabilities. The principles set out in Briginshaw v Briginshaw8 are applicable. This means that the more significant the issue to be determined, the more serious an allegation or the more inherently unlikely an occurrence, the clearer and more persuasive the evidence needed for the trier of fact to be sufficiently satisfied that it has been proven to the civil standard. A coroner also is obliged to comply with the rules of natural justice and to act judicially. This means that no findings adverse to the interest of any party may be made without that party first being given a right to be heard in opposition to that finding.

SC BRETT FORTE

23. Brett Andrew Forte was born on 25 August 1975 at Redcliffe, Queensland. He was aged 41 at the time of his death. SC Forte was a devoted husband and father. He and Susan cared for three children, Emma, Brodie and Samuel.9

24. SC Forte came from a family with a proud history of serving the community as police officers. Both his father and grandfather had served in the QPS. He commenced his service as a cadet at age 26 in May 2001, and had been stationed at Ipswich, Cunnamulla, Caboolture and Toowoomba. At the time of his death he held the rank of Senior Constable within the Toowoomba TCS. He was a well-loved member of the police community.

25. SC Forte was recognised as a leader who mentored junior officers. He enhanced morale among his colleagues with his sense of humour. His service and bravery have been recognised with the Queensland Police Service Medal, the National Police Service Medal, the National Medal, and the Queensland Police Service Valour Award.

26. I extend my sincere condolences to Mrs Forte and to the family and friends of SC Forte.

He was clearly loved by his family and work colleagues. Mrs Forte’s grief was undoubtedly amplified by the fact that she was on duty at the time of her husband’s death and heard the tragic events as they unfolded over the police communications network.

8 Briginshaw v Briginshaw (1938) 60 CLR 336 at 361 9 Ex A5, pg. 20 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 5 of 82

27. I acknowledge Mrs Forte’s courage in participating in this inquest, and the particular challenges it presented as she was both the victim of the horrendous acts perpetrated against her husband, and a serving member of the QPS. In the course of the coronial investigation, she was entitled to answers about the circumstances surrounding SC Forte’s death in both capacities.

RICKY MADDISON

28. Ricky Charles Maddison was born in Bundaberg on 13 December 1976 and was 40 years of age when he died.

29. Mr Maddison had a criminal history in Queensland with convictions for various offences, including assault occasioning bodily harm, wilful damage, and other minor property offences.10

30. Mr Maddison had operated a plastering business for over 10 years. He was reported to have had an active social life with a good circle of friends. However, his behaviour deteriorated in the two years before his death. This coincided with the commencement of his relationship with Ms B in July 2015.11 In October 2015, he also had a motorcycle accident where he dislocated his shoulder. He was unable to work for a period which caused financial difficulties, as did the legal fees relating to defending criminal matters.12 He underwent shoulder surgery in 2017.

31. At the time of his death, Mr Maddison had been living “off-grid” in a shed at 162 Wallers Road.13 This property was owned by the family of Mr Maddison’s friend, Adam Byatt. He had rented the property since January 2017.14 It appeared that Mr Maddison’s relationship with his family had also deteriorated.15

32. Mr Maddison and Mr Byatt had reconnected in 2016. Mr Byatt was aware of the legal and financial difficulties Mr Maddison was experiencing after contesting criminal charges associated with domestic violence. In January 2017, Mr Maddison expressed an interest in living at the Wallers Road property owned by Mr Byatt’s parents. The property had been used for recreational shooting and rifle target practice.16 Mr Maddison rented the property, which Mr Byatt visited regularly. He initially paid cash rent, but it was later deposited the directly to Asia Byatt’s account by her son. Adam Byatt and Mr Maddison engaged in shooting practice at Wallers Road and Mr Byatt was aware Mr Maddison had centre fire rifles.17

33. In early 2017, Mr Maddison had borrowed his brother’s Nissan Navara. He claimed he needed a vehicle with some ground clearance.18 10 Ex C2; Ex C1 11 Ex A7, pg. 7 12 Ex A7, pg. 8 13 Ex A7, pg. 5 14 Ex A5, pg. 541 15 Ex A7, pg. 7 16 Ex A7, pg. 8; 142 17 Ex A7, pg. 8 18 Ex A7, pg. 8 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 6 of 82

34. Mr Maddison regularly attended his local General Practitioner, for various health issues.

This included his mental health and wellbeing, which were an ongoing concern. On 20 February 2017, Mr Maddison saw his GP and reported feelings of worthlessness, anxiety and depression. The GP formulated a mental health plan and Mr Maddison was referred to a clinical psychologist. It was noted at the time that Mr Maddison was not suicidal or a risk to others.19

35. Mr Maddison engaged with a psychologist on 6 and 20 March 2017.20 He reported during these sessions that he had feelings of helplessness due to the complaints made by Ms B and the actions of police. He felt police were targeting him. He was struggling financially as a result of having to defend the criminal charges and was living in isolation, hiding from the police. The psychologist considered that Mr Maddison was suffering from extreme depression, anxiety and stress. Mr Maddison missed a further appointment on 29 March 2017.

36. Apart from engaging with the psychologist, Mr Maddison had no mental health history in Queensland. I also extend my condolences to Mr Maddison’s family.

MADDISON’S HISTORY OF VIOLENCE AGAINST WOMEN 2015 charges

37. Mr Maddison and Ms B had dated briefly in 2006 and in July 2015 they commenced an intimate relationship. They started living together with Ms B’s two young children.

38. Mr Maddison’s relationship with Ms B was characterised by extreme coercive control.

From the outset he sought to create a climate of fear, isolation, intimidation and humiliation. He was physically and non-physically violent and abusive. She knew he had the capacity to cause serious harm to her.

39. Ms B’s actions in response to the assistance the QPS provided in relation to domestic violence and criminal proceedings, such as being reluctant to give evidence against Mr Maddison, must be considered in that context. It was unfortunate that some police officers perceived her simply as an unreliable witness.

40. On 10 September 2015, Ms B went to the Toowoomba Police Station and made a complaint against Mr Maddison. She alleged that since 15 August 2015 she had been subjected to a number of protracted assaults over various periods causing an array of injuries. The particulars of each assault are outlined in further detail below.

41. On 11 September 2015, a temporary Domestic and Family Violence Protection Order naming Mr Maddison as the respondent was sought by Constable Nathan McIntosh.21 The application was scheduled to be heard on 30 September 2015 in the Toowoomba Magistrates Court. The grounds for the protection order included:22

• On 15 August 2015, Mr Maddison and Ms B had a verbal argument at her residence. Mr Maddison confronted Ms B about the content of an email with another male after having gone through her telephone. He accused Ms B of cheating. He then head butted her, causing her to fall to the ground.

19 Ex A7, pg. 9 20 Ex A7, pg. 9 21 Ex C42 22 Ex C42, pg. 7 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 7 of 82

• On 16 August 2015, Mr Maddison and Ms B had a further argument about a female work colleague. Mr Maddison allegedly put his hands around her throat, after which Ms B called out for her daughter. He ceased when he saw the child.

• On 28 August 2015, Ms B returned home to find Mr Maddison drinking. He became agitated and an argument ensued. Ms B attempted to leave by getting into her vehicle. Mr Maddison dragged her out of the vehicle and along the floor to the shed.

He proceeded to strike her several times with an open hand and was yelling. Mr Maddison then kicked and punched her a number of times. He kept Ms B in the shed until 2-3:00 am. The following day he apologised. Ms B took leave from her employment and sought medical care for her injuries.

• On the afternoon of 5 September 2015, having argued during the day, Mr Maddison is alleged to have followed Ms B into the bedroom and accused her of talking to other males. At around 8:00 pm that night, he asked about it again before placing his forearm across her throat and producing a knife. He poked the knife into her nostrils and dragged it across her throat. Mr Maddison grabbed her hair and dragged her through the house while striking her. He made repeated threats to kill Ms B. He proceeded to question her at length about previous relationships and would strike her with an open hand before choking her. He also poured petrol over her and threatened to set her alight. The assaults continued until around 6:00 am and resulted in a punctured lung.

• On 10 September 2015, Mr Maddison threw a drink in Ms B’s face following an argument when she returned home. After demanding she tell him what she was doing, he subsequently grabbed her by the hair a number of times and struck her with a book.23

42. The application noted that Mr Maddison had made threats of retribution should Ms B seek assistance from the police.24 Due to the nature of the allegations, police were of the view that a DV Order (DVO) was necessary and desirable to protect Ms B due to the ‘extremely serious nature of the incidences of domestic violence that have repeatedly occurred over the duration of the relationship’.25 It was noted that Mr Maddison was in possession of a number of knives. Firearms were not mentioned.

43. On 11 September 2015, Ms B attended the Toowoomba Hospital seeking treatment for her injuries. A number of bruises over her body and wounds were noted.26

44. A temporary protection order was put in place before the application was heard. This contained the standard provisions with respect to good behaviour. Mr Maddison was required to leave the residence, not return or approach Ms B in any way through any party.27

45. On 11 September 2015, Detective Senior Constable (DSC) Lowe from the Toowoomba Criminal Investigation Branch (CIB) commenced an investigation into the allegations.28 23 Ex C46.1, QP9 – charge 16 (not in DV application) 24 Ex C42, pg. 10 25 Ex C42, pg. 8 26 Ex C51 27 Ex C42.1 28 Ex A5, pg. 3; Ex C54 chronology (redacted) Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 8 of 82

46. A QPS intelligence report relating to Mr Maddison from this date indicated that he had previously been charged with assault offences, including domestic violence, and was known to have a number of knives throughout his dwelling.29 It was noted that he was ‘believed to be in possession of a cross bow and has told the victim of the current incident that he had a Glock pistol, although this has not been sighted by the victim.’30

47. On 12 September 2015, DSC Lowe swore an arrest warrant for Mr Maddison in relation to the following 17 offences:31

• Assault occasioning bodily harm x 9

• Deprivation of liberty x 2

• Torture x 2

• Threatening violence

• Wounding

• Common Assault

• Producing Dangerous Drug

48. Police commenced attempts to locate Mr Maddison with respect to the warrant. On 17 October 2015, DSC Lowe had a conversation with Mr Maddison over the telephone whereby he indicated he would surrender on 19 October 2015.32

49. On 19 October 2015, Ms B attended the Toowoomba Police Station and indicated that she wished to withdraw her complaint about the criminal offences. However, she asked that the DVO remain in place.33 In the signed withdrawal, Ms B indicated that she was fearful of what Mr Maddison may do if the charges proceeded. Mr Maddison failed to present to police that day.34

50. On 20 October 2015, Mr Maddison contacted DSC Lowe and asked that the arrest warrant be cancelled so that he could seek medical treatment. He was advised about the temporary DVO, which had a court mention date scheduled for 28 October 2015.35

51. On 20 October 2015, DSC Lowe sought formal written approval from the Officer in Charge of the Toowoomba Criminal Investigation Branch (CIB) to withdraw the charges against Mr Maddison.36 DSC Lowe recommended that the charges be withdrawn, except for those pertaining to Producing Dangerous Drug, and that the DVO continue to be in place.37 He noted:38 It is recommended that these matters be withdrawn in light of the wishes of the complainant. While she is still cooperative with Police, she is no longer supportive of the matters proceeding criminally. While there is sufficient evidence to commence proceedings, the complainant’s evidence is crucial to these being successful. Given that she no longer wishes to proceed at this time, the likelihood of it progressing through the courts is not likely.

29 Ex C50 30 Ex C50, pg. 1 31 Ex A5, pg. 3; Ex C46.1 – QP9’s for offences 32 Ex C54, pg. 1 33 Ex A5, pg. 4; Ex C85 34 Ex C54, pg. 1 35 Ex C54, pg. 1 36 Ex C85.1 37 Ex C85.1, pg. 1 38 Ex C85.1, pg. 5 & 6 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 9 of 82

The complainant has thoroughly considered the decision to withdraw the complaint, as is evidenced by the lengthy conversation with Police. She is aware of the risk associated with the charges against Mr Maddison being discontinued, however has made an informed decision that she believes that this is the best decision for her ongoing safety in the future.

52. In response to DSC Lowe’s formal request, a memorandum was completed by the OIC, Toowoomba CIB, Detective Snr Sgt McCusker. Detective Snr Sgt McCusker was not supportive of the charges being withdrawn citing a previous DV complaint against Mr Maddison from 2009, which was said to be similar, and also withdrawn.39 He noted that the reasoning behind Ms B’s request seemed naïve and that Mr Maddison had a propensity to commit violent offences and would be a high-risk of committing future domestic homicide.40

53. A further report was then prepared by Sgt Hutton, OIC of Police Prosecutions in Toowoomba with respect to the request to withdraw the charges.41 Officer Hutton cited the medical evidence as supportive of Ms B’s account, as well as the property damage found at the residence. He argued that should she attend and be unwilling to provide evidence; she could be declared hostile. It was argued that there would be a ‘very strong’ public interest in having the charges proceed and there was a ‘very high level of culpability’ of the defendant.42 Officer Hutton shared the concern expressed by Detective Snr Sgt McCusker that such violence can be indicative of domestic homicide in the future. Accordingly, he was of the view that the charges should proceed.43

54. After considering the competing views about the withdrawal of the charges against Mr Maddison, on 21 October 2015 Detective Inspector Isherwood directed that the criminal charges continue.44 In reaching this decision, Inspector Isherwood noted:45 I would also like to acknowledge that under normal circumstances a complainant’s wish to withdraw their complaint is given paramount consideration with respect to the continuance of a prosecution, and usually I would be pleased to accent to their wishes.

However, the allegations made by this complainant relating to ongoing domestic violence are at a level of violence that can only be considered as extreme, and I hold grave concerns for the well-being of the complainant regardless of whether the complaint is withdrawn or not.

The suspect Mr Maddison’s propensity towards violence is well documented and such propensity has escalated considerably over the years to a level where profiled he would display all the characteristics of a person susceptible to homicidal tendencies.

Upon serious consideration of all the facts relating to this matter, I am of the opinion that there is sufficient corroborative evidence including medical, forensic and independent witness statements, other than what can be relied upon in the complainant’s statement to support a prima facie prosecution against Mr Maddison.

55. Despite making prior arrangements, Mr Maddison again failed to present to police on 4 November 2015.46 39 Ex C85.2 40 Ex C85.2, pg. 2 41 Ex C86.3 42 Ex C86.3, pg. 2 43 Ex C86.3, pg. 3 44 Ex A5, pg. 4; Ex C54, pg. 2; Ex C89 45 Ex C89, pg. 1 46 Ex C54, pg. 1 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 10 of 82

56. On 6 November 2015, another email was received from Ms B asking that both the charges and DVO against Mr Maddison be withdrawn.47 She made it clear that she did not want to participate in court proceedings and asked that the charges be withdrawn a number of times. Ms B stated, ‘…I am not fearful of him or for my safety’.48

57. Ms B stated she only initially wanted the DVO to be put in place. However, the Constables who interviewed her were ‘very forthcoming’ in wanting her to lay the charges and gave her little time to consider it. She also stated that she had been using heavy pain killers since the initial interview. Consequently, any further statements made by her may be conflicting with the events that took place.49 At the end of the email, Ms B stated: I would like to make an application to have the DVO also removed or amended so that contact can be made between myself and Ricky Maddison. I in no way feel unsafe and would like to be able to contact Rick for the sake of myself and my children.50

58. On 9 November 2015, DSC Lowe emailed Ms B advising that she needed to provide a sworn affidavit detailing her request to withdraw the charges and DVO.51 The DVO hearing scheduled for 11 November 2015 was adjourned pending the consideration of Ms B’s request to withdraw.

59. On 13 November 2015, Mr Maddison attended the Toowoomba Police Station where he was interviewed and served with the order by DSC Lowe.52 He was also charged with the offences relating to the incident in September 2015 and was released on bail later that day.53

60. Mr Maddison provided a range of documents to police, which indicated Ms B had continued to contact him, and attempted to contact him in October 2015.54

61. On 25 January 2016, an affidavit from Connolly Lawyers on behalf of Ms B was received requesting that the charges against Mr Maddison be withdrawn.55 Relevantly, her statement noted:56 [12] During the course of providing my witness statements to Police, I was heavily medicated due to my injuries and do not believe that I was able to make a free and informed choice regarding the making of the complaint against Mr Maddison.

[14] I am not fearful for my safety and/or the safety of my children as I will not be having any further contact with Mr Maddison. I believe that Mr Maddison will not be of any risk to myself and/or my children if the charges are withdrawn.

[15] I believe that if I am required to give evidence at any future date against Mr Maddison for the charges brought against him, this would only cause me more heartache and stress than is required. I am wanting to put the entire matter behind me in order to better my own life and those of my children.

47 Ex C54, pg. 2; Ex C92 - email 48 Ex C92 49 Ex C92 50 Ex C92 51 Ex C93 52 Ex C54, pg. 2 53 Ex A5, pg. 4 54 Ex C97, various pg. including 31-38 55 Ex C54, pg. 2; Ex C93.1 56 Ex C93.1, pg. 4 & 5 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 11 of 82

62. It is unclear what consideration Ms B’s subsequent request to withdraw the charges was given by DSC Lowe or other officers. However, the QPS was clearly of the view that the charges should be maintained. It proceeded with the charges against Mr Maddison, which were listed for a committal hearing.

63. On 9 March 2016, legal representatives for Mr Maddison asked to cross examine Ms B on various topics.57 DSC Lowe provided advice to Police Prosecutions about the matters raised.58 Following legal argument, Mr Maddison’s representatives were successful in their application to cross examine Ms B at the committal hearing.59

64. On 18 August 2016, Ms B applied to vary the DVO, seeking to remove the no contact provisions.60 Ms B’s application stated that Mr Maddison had abided by all the DVO requirements, and she did not want to continue with the associated charges. She said that “I feel and know I am safe”.

65. In September 2016, a successful application was made for Mr Maddison’s representatives and Police Prosecutions to inspect medical records relevant to Ms B.61

66. On 23 September 2016, Ms B was formally summonsed to appear at the committal hearing, which was listed in the Toowoomba Magistrates Court on 11 October 2016.62 Ms B failed to appear on this date, and a warrant was initially issued for her arrest.

67. The charges against Mr Maddison were subsequently discontinued and the warrant for Ms B’s arrest was revoked. 63 Ms B was advised of this outcome on 12 October 2016 by DSC Lowe, who stated, ‘they may be re-initiated in the future, however, will not be able to be done so without your cooperation.’64 Further charges - 2017

68. In February and March 2017, Mr Maddison called Ms B to arrange for the collection of property from her residence. She offered to drop the items at Mr Maddison’s brother’s house. As the DV Order was still in place with a no-contact condition, his calls were in breach of the order.65

69. At around 9:26 pm on 12 March 2017, Mr Maddison went to Ms B’s home at Penderests Road, Murphys Creek, to collect property.66 He was angry, and an argument ensued.

According to Ms B, Mr Maddison produced a pistol from behind his back and fired it above his head. He also put the gun to his chin and pointed it at Ms B during the argument. He accused her of ‘taking everything from him’. He left the residence without taking any of his property. Ms G, who was staying with Ms B, witnessed the incident.

57 Ex C102 58 Ex C102.1 59 Ex C109 60 Ex A5, pg. 4 61 Ex C106 62 Ex C110 63 Ex C54, pg. 2; Ex C114 64 Ex C114 65 Ex A7, pg. 9 66 Ex A7, pg. 9; Ex C120; Ex C121 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 12 of 82

70. On 13 March 2017, Ms B went to the Gatton Police Station and made a complaint about the incident the previous evening. She spoke to Detective Senior Constable (DSC) Petrie. Ms B was subsequently contacted by Senior Constable Susan Forte, the Toowoomba District Domestic Violence Project Officer. Her role was responsible for considering all DV occurrences in the Toowoomba District and conducting a risk assessment. If a risk was perceived to be high, SC Forte worked with the aggrieved and tried to locate the respondent.67

71. Over the next few weeks, officers attempted to locate Mr Maddison in order to question him about the incident on 12 March 2017. Although agency checks were also conducted, including Centrelink and Medicare, it appeared he was actively living ‘off the grid’.

72. An Officer Safety Alert was issued with respect to Mr Maddison on 12 March 2017, which described the incident at Penderests Road. It stated, ‘Officers are to exercise caution and ensure they Consider all Options and Practice Safety in any dealings with the above’.68

73. On 13 March 2017, the Toowoomba Patrol Group taskings included Mr Maddison. It was noted he was wanted for questioning, and a caution/flag was included for firearms as well as Outlaw Motorcycle Gangs (OMCG) associations.69

74. Mrs Forte continued to actively engage with Ms B, who was seeking assistance from various organisations, including the Domestic Violence Action Centre and Relationships Australia. Arrangements were made for cameras to be installed at the address where the incident had occurred and for a SafeTCard70 to be issued as well.71 It was repeatedly highlighted that Mr Maddison was ‘really dangerous’ and that Ms B was at ‘great risk’.72

75. On 15 March 2017, Mr Maddison contacted Ms B by telephone. He was attempting to apologise before becoming aggressive and angry once he was made aware that Ms B had advised police of the incident on 12 March 2017.73

76. As early as 20 March 2017, officers thought SERT may need to be involved in the arrest of Mr Maddison due to the use of firearms in the offences and the need for a specialist policing response, including a possible search of bushland.74 It was asked that an intelligence profile be developed in the event it was required.75

77. At around 11:00 am on 27 March 2017, Mr Maddison was captured on CCTV attending Ms B’s residence again in a silver dual cab utility. She was staying elsewhere following the previous incident.76 67 Ex A5, pg. 342 68 Ex C121 69 Ex C122 70 Ex C125.10 (brochure) 71 Ex C125.4 72 Ex C125.4, pg. 2 73 Ex C125.6 74 Ex A7, pg. 9 75 Ex A7, pg. 9 76 Ex A7, pg. 10; Ex C133 (footage) Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 13 of 82

78. There were 18 officers within the TCS. Senior Sergeant Stahlhut was the Officer in Charge of the Unit. He was also responsible for a secondary team of four officers, the Tactical Action Team (TAT), which focused on matters relating to the activities of OMCGs. Officers rotated within the TCS to TAT, and from other units outside. The team leader for the TAT was Sgt Dan Curtain.

79. On 29 March 2017, Sgt Loveday from Toowoomba TCS spoke with Mr Maddison by telephone in relation to the complaint made by Ms B and a breach of the DV Order.77 He asked that Mr Maddison attend the station in relation to the offences. Mr Maddison refused and raised the discontinued allegations in 2016. He was told the general nature of the allegations only.78

80. On 30 March 2017, Ms B provided a statement to police asking that the charges against Mr Maddison be reinstituted.79 Ms B indicated that on the previous occasion, she did not attend the committal proceedings because she did not want to be re-traumatised in the process by having to answer questions about Maddison’s assaults and torture.

81. On 31 March 2017, DSC Lowe prepared a memorandum to the OIC of the Toowoomba Child Protection and Investigation Unit seeking a direction to reinstitute the charges against Mr Maddison.80 While the possibility that Mr Maddison may seek a stay of proceedings was considered, it was recommended that the charges be recommenced.81

82. On 6 April 2017, Mr Maddison attended his GP as he had fallen and injured his shoulder.

He reported that he was still ‘down’ and was living in a shed.82

83. On 11 April 2017, SC Brett Forte of the Toowoomba TCS swore an arrest warrant for Mr Maddison for the offence of ‘Contravene a domestic violence order’ based upon CCTV footage from Ms B’s residence.83 The complaint was taken to Mrs Forte as the Domestic Violence Project Officer. Mrs Forte had been working with Ms B since her complaint in March 2017.84

84. On 24 April 2017, advice was received supporting the reinstatement of the 2015 charges against Mr Maddison by the Toowoomba District Office and Police Prosecutions.85 Despite the possible legal issues, it was recognised that it would be in the public interest given the serious nature of the allegations.86

85. On 28 April 2017, an arrest warrant was issued to recommence the proceedings.87

86. On 8 May 2017, in breach of the DVO in place, Mr Maddison contacted Ms B via a pay telephone during which he stated, ‘Is it not enough that I’m broke and homeless and you want me to go to jail? Are you enjoying your new life?’88 The following day he sent her a text message.

77 Ex C151.1 (transcript of call) 78 Ex A7, pg. 10 79 Ex C54, pg. 2; Ex C142, pg. 14 (copy of statement) 80 Ex C142 81 Ex C142, pg. 3 82 Ex A7, pg. 10 83 Ex C128, pg. 67; Ex C160; Ex A5, pg. 345 84 Ex A7, pg. 10 85 Ex C54, pg. 2 86 Ex C143, C144 & C145 87 Ex C54, pg. 2; C146 88 Ex C128, pg. 98 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 14 of 82

87. According to minutes from a Toowoomba OIC, CIB, Tactical Crime management meeting held on 9 May 2017, Mr Maddison was identified as the most wanted via an email sent from A/Snr Sgt Sheldrick, Darling Downs District Tactician.89

88. On 11 May 2017, Ms B received two text messages from Mr Maddison, which had been sent from a payphone.90

89. On 17 May 2017, Gatton Police had commenced surveillance of the entrance of Mr Maddison’s property on Waller Road following reports of automatic gunfire in the area.

A Cuddeback camera was installed in a tree on the corner of the property opposite the gate leading to the shed where Mr Maddison was residing.91

90. On 17 May 2017, Mrs Forte swore an arrest warrant for Mr Maddison with respect to contravening a Domestic Violence Order.92

91. On 18 May 2017, Adam Byatt visited Mr Maddison at the Wallers Road property. When he was leaving at around 12:53 pm, Mr Byatt saw Senior Constable (SC) Andre Thaler from the Toowoomba TCS, who was off duty at the time. SC Thaler was walking along Wallers Road carrying binoculars and his QPS QLITE device.93 Mr Byatt was suspicious and spoke to SC Thaler. He then sent a photograph of SC Thaler to Mr Maddison to warn him.94 Mr Maddison queried whether SC Thaler was a trespasser. Mr Byatt responded via text that he was unsure, and that SC Thaler was walking with an iPad, binoculars and no water.

92. Following his encounter with Mr Byatt, SC Thaler furnished an intelligence report.95 He was actively looking for Mr Maddison but unaware how close he was to his hideout. SC Thaler also had no awareness of the Gatton Police investigation into automatic weapon fire in the vicinity. SC Thaler said that it was subsequently believed that Mr Maddison may have been camping in bushland in the Gatton area. However, this was not until after he was seen on CCTV loading ice into his vehicle at the BP Service Station at College View on 24 May 2017.

93. SC Thaler told the inquest that he had worked with TCS since 2013. Mr Maddison was well known locally in the district by QPS. Several targeted attempts and inquiries had been made by TCS to locate him, which intensified between 27 March and 18 April 2017.

However, his involvement in those searches commenced from around 20 May 2017.

94. SC Thaler denied that he spent ‘a fair amount’ of his own time looking for Mr Maddison or gathering intelligence that would assist in locating him. He denied that there was an A Team and B team within TCS, rather there were different roles within the unit.

95. In relation to the decision to hike into the Lockyer National Park via Wallers Road on 18 May 2017, SC Thaler said: 89 Ex C128, pg. 86 90 Ex A7, pg. 10 91 Ex A7, pg. 10 92 Ex C128, pg. 101; Ex A5, pg. 5 93 Ex A7, pg. 10 94 Ex A7, pg. 11 95 Ex C128, pg. 124 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 15 of 82

• He only made the decision to hike the national park late on that day, having previously been to a number of other parks within the district. He was on a day off.

• He was unaware of any criminal intelligence or reports of automatic gunfire in the area or links to Mr Maddison prior to the decision to access Wallers Road that day.

• He described Adam Byatt as confrontational and aggressive during his encounter, and he had concluded, given his demeanour, that Mr Byatt was a person of interest and there may be suspicious activity on the property. He subsequently made a note of his registration on his QLite device.

• He spent a few hours in and around the national park before exiting and returning to his vehicle parked on Wallers Road.

• Upon completing his Intel report following the encounter, and identifying the male as Mr Byatt, there was no known link to Mr Maddison.

• On 22 May 2017, he was contacted by A/Sgt Brad Smart from Gatton Station about the reports of automatic gunfire on Wallers Road after A/Sgt Smart saw the Intel report he submitted in relation to Mr Byatt. He advised Officers Stahlhut, Jenkins and Curtain about the email chain. He forwarded his email exchange with A/Sgt Smart at 7:01pm.96

• He denied that he had attended Wallers Road to gather intelligence about the layout of the property suspected of being related to Mr Maddison.

96. On 19 May 2017, Sgt Peter Jenkins of the Toowoomba TCS made a request seeking SERT assistance to search the bushland at Penderests Road, Murphy Creek around Ms B’s residence, where it was suspected Maddison was hiding in a cave.97 It was noted that Mr Maddison was known to have a handgun, which was described as ‘pirate gun’.98 SERT deployment was approved, and it was classified as a ‘high-risk’ deployment.

97. On 21 May 2017, SERT officers in company with CIB and TCS were deployed to search bushland believed to be where Mr Maddison was camping in the vicinity of Ms B’s previous residence at Murphys creek.99 SERT in company with CIB officers went to known addresses of Mr Maddison’s associates.100

98. Mr Maddison was not located during the search or at any of the residences.101 An overview of the attempts made to locate Mr Maddison was outlined in a High-Risk Case Management Report.102

99. On 22 May 2017, DSC Scott Petrie of the Gatton CIB swore an arrest warrant for Mr Maddison for alleged offences committed on 12 March 2017 of Contravene DV order and Common Assault based on Ms B’s complaint.103 96 Ex J25.2 97 Ex C41 (referred to incorrectly in Mr Maddison Coronial Report as C19) 98 Ex C41, pg. 2 99 Ex A5, pg. 5 100 Ex A5, pg. 5 101 Ex A7, pg. 11 102 Ex C127 103 Ex A7, pg. 12; Ex A5, pg. 5 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 16 of 82

100. On 24 May 2017, Mr Maddison’s bank records were obtained. TCS officers identified he had been conducting transactions at the BP Service Station, College View, near Gatton.104 It was inferred he may have been staying in the Gatton area and may be camping in bushland. An Officer Safety Alert issued for Mr Maddison indicated that he had been the target of recent SERT actions.

101. It was stated that ‘Investigating police from the Darling Downs Tactical Crime Squad are conducting extensive patrols and inquiries on 25 May 2017 in an attempt to locate the wanted person MADDISON. MADDISON is possibly in possession of a firearm and is considered dangerous’.105

102. In an email sent from Sgt Dan Curtain, Darling Downs TCS, to the Southern Region on this date, it was noted that ‘Mr Maddison is dangerous and possibly armed with a firearm.

He has been the recent target of SERT actions. Please exercise all caution in any dealings with him’.106

103. At 4:20 pm on 24 May 2017, Mr Maddison called the Toowoomba CIB reception office requesting to speak to DSC Lowe.107 As Lowe was unavailable, he spoke to SC Cath Nielsen, who was unable to record the conversation. Mr Maddison was ‘extremely aggressive’ and appeared to be punching the phone box during the course of the telephone call.108 He indicated that Police were harassing his family and that he would not hand himself in.

104. On 26 May 2017, Mr Maddison located the camera installed by Gatton Police opposite the entrance to the Wallers Road property as part of their investigation into fully automatic machine gun fire in the area.109 He can be seen in images later captured from the SD card of the camera with an automatic weapon slung over his shoulder. He relocated the camera to high in a tree inside the driveway of the Byatt property, near his stronghold.

105. Toowoomba Police were oblivious to the existence of the camera or the Gatton investigation. As the investigation report noted, it is likely that locating the camera, which had ‘Gatton Police’ inscribed on the side, would have undoubtedly added to Mr Maddison’s paranoia that police were after him, particularly after SC Thaler’s encounter with Mr Byatt the previous week.110 It is likely that this prompted him to tell police that they knew where he was located when he spoke with Sgt Jenkins on 29 May 2017.

106. On 27 May 2017, Mr Byatt saw Mr Maddison at around 5:00 pm after attending the Wallers Road property to play chess. Nathan Byrne also attended this day to ride motorbikes.111 They discussed the placement of the Cuddeback camera.

104 Ex A5, pg. 5 105 Ex C126 106 Ex C128, pg. 139 107 Ex C128, pg. 140 & 141 108 Ex C128, pg. 141 109 Ex A7, pg. 72 110 Ex A7, pg. 73 111 Ex A7, pg. 12 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 17 of 82

107. On 28 May 2017, Mr Hadley and his wife, who was an employee of Asia Byatt, attended the Wallers Road property to ride motorbikes, having been given permission and a key to access the property. Mr Maddison spoke to them while they were riding and as they were leaving the property. Jamie recalls seeing that Mr Maddison had a number of motorbikes at the property, however, did not see any firearms or ammunition aside from a BB gun.112

108. On this date, Snr Sgt Stahlhut, TCS advised SERT Intel of information relating to Mr Maddison’s bank accounts and the likelihood he would withdraw Centrelink funds on 30 May 2017.113

109. On 28 May 2017, Mr Maddison spent the night at long term friend, Andrew Beveridge’s house in Wilsonton. They smoked ICE and Mr Maddison stayed for the night, sleeping on the lounge.114

110. Snr Sgt Stahlhut told the inquest Operation Oscar Atrium was a case in place model, whereby the city patrol weekly meeting would focus and target on high risk DV offenders, of which Mr Maddison had been identified.115 His apprehension was considered a high priority.116 Following the SERT action at Penderests Road, TCS confirmed they had carriage of locating Mr Maddison for breach of DV.117

111. The risk Mr Maddison posed as known by the TCS team was described by Snr Sgt Stahlhut as ‘extreme’, confirmed by a number of BOLO’s issued in relation to his whereabouts.118 From 22 May 2017, the focus of the squad was to locate high risk offenders including Mr Maddison.119

112. Information was received from Mrs Forte, who was the DV Project Officer through to Snr Sgt Stahlhut, and on occasion through SC Forte, which was demonstrated in emails.120 Snr Sgt Stahlhut denied there was ever a link made by TCS or SERT between Mr Maddison and Wallers Road.121 In relation to sending Sgt Jenkins to the communications room during the pursuit, he noted that the intention of this was to provide a reference point and to provide further information posed to the Comco, particularly in terms of the risk Mr Maddison.122 112 Ex A7, pg. 12 113 Ex A5, pg. 5 114 Ex A7, pg. 12

115 T6-8 116 T6-10 117 T6-9 118 T6-10 119 T6-11; Ex B17.3

120 T6-15 121 T6-20 122 T6-26 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 18 of 82

EVENTS OF 29 MAY 2017

113. At around 8:00 am on 29 May 2017, Police attended upon Mr Maddison’s GP and asked that he advise them the next time Mr Maddison was due to attend. The GP indicated that he would seek legal advice about whether he could disclose this information.

114. That morning, Mr Maddison visited a friend to retrieve an old T-shirt before traveling to Beveridge’s home. He left to buy some cans of alcohol at Wyalla Plaza. He returned shortly after, furious as he claimed his pension had been ‘cut off’ and he had no money.123 He was in fact paid his Newstart Allowance the following day, so had not been ‘cut off’.

115. After arriving back from the shops, Mr Maddison showed Beveridge a ‘heap of guns’ that he had placed in the rear seat of his vehicle.124 He told Beveridge, ‘It’s only when I become big news will anyone look at my case’.125

116. Beveridge asked Mr Maddison to come to the Gold Coast with him. Mr Maddison declined stating, ‘Nah everything is already arranged’.126 Beveridge gave Mr Maddison $20 to pay for fuel before he left. At the inquest, Beveridge said Mr Maddison had shown him the guns the evening before but made the comment about becoming ‘big news’ on 29 May 2017.127 He said Mr Maddison thought the police were out to get him, particularly after he found a police camera overlooking his property.128 Mr Beveridge said that Mr Maddison referred to officers, who were known to be husband and wife (presumably SC Forte and Mrs Forte) who he felt were ‘setting him up’ and targeting him, although he expressed no plan to confront them

117. On 29 May 2017, SC Brett Forte was rostered to perform duty from 8:00 am until 4:00 pm. Intelligent Analysis System (ITAS) activity logs indicate early in the shift that SC Forte, with other TCS officers, executed a search warrant at an address in Drayton before returning to the Toowoomba Station at around 12:05 pm.129

118. At around 12:50pm on 29 May 2017, Mr Maddison called his brother, Shane from a public pay phone. They spoke briefly about family before the credit being used ran out.

119. At 1:11 pm, Mr Maddison bought fuel from the BP Service Station on Mary Street, Toowoomba.

Phone call with Detective Sgt Peter Jenkins, Toowoomba TCS130

120. At 1:16 pm, Mr Maddison used a phone box on Lindsay Street, Toowoomba to contact Toowoomba Police Station (approximately 800 m away). 131 He spoke to SC Brett Forte and asked to speak to ‘the senior officer’. He was subsequently transferred to Sgt Jenkins of the Toowoomba TCS.132 123 Ex A7, pg. 13 124 Ex A5, pg. 574 125 Ex A7, pg. 13 126 Ex A5, pg. 575

127 T1-69 & 70 128 T1-71 129 Ex A5, pg. 6 130 Ex G39 (transcript of call); also contained as audio in Ex D1 timeline 131 Picture of location, Ex A7, pg. 14 132 Ex A7, pg. 13 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 19 of 82

121. During this conversation, Sgt Jenkins asked Mr Maddison to surrender to have the matter investigated. Mr Maddison stated that the previous complaints by Ms B were not investigated appropriately, and he did not wish to come in until they were properly considered.133 Early in the phone call Mr Maddison stated:134 MADDISON: I’ve, I’ve been fucked over. If you’ve actually looked at the fucking case and looked at all the shit that woman fucking wrote what happened, the accusations she fucking made, all the accusations she’s made about other 100 men beforehand her ex-husband all the bloody dating sites, all, all fucking um all, all, all the public forums she’s written all this shit about all her ex’s. Have you looked at any of that?

JENKINS: Ricky my, our job … MADDISON: Look your, your job is to go on prima facie you could not give a flying fuck about the truth. What you do is you take someone’s complaint and try and fucking lay as many charges as you can.

JENKINS: So you’re saying that we shouldn’t believe anyone else just you, is that what you’re trying to say?

122. Mr Maddison continued to refer to Ms B’s complaint from 2015. These statements include: You guys fought tooth and nail to keep the case going135 Are, are, are you missing my point I spent two years trying to prove my last case and then right at the last minute youse went and discontinued136 Why do I need to youse don’t listen. I brought in over seven or eight hundred pages of evidence to disprove my case last time and while I was locked up for six or seven hours before I saw the magistrate they tossed it aside they didn’t fucking read a fucking thing.

No one listened to a word I had to say or any of the evidence I brought in so why the fuck would I come in and talk when youse don’t listen.137 …refused bail and loaded me up with seventeen charges because youse know youse have fucking mentally financially fucking ruined and broken me and I don’t have any fucking where else to turn.138 Oi as I said what are you dim mate I am not there, I have not been there. If you ask any of ‘em they haven’t seen me in fucking six to nearly twelve months because I can’t face anybody anymore I’m a fucking broken man. I used to be a proud fucking businessman I, I used to, I used to be proud now I fucking have trouble finding a reason to get out of bed.139 I’m not going to jail, I’m not spending one more cent over this lying bitch because I spent two years disproving all her fucking shit and the minute she wants to fucking UI hey here we go again.140 133 Ex G39, various including pg. 1, 20, 21 134 Ex G39, pg. 4 135 Ex G39, pg. 5 136 Ex G39, pg. 5 137 Ex G39, pg. 8 138 Ex G39, pg. 13 139 Ex G39, pg. 18 140 Ex G39, pg. 26 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 20 of 82

123. Mr Maddison is angry and agitated during the call. He stated he has lost ‘everything’, including his business, house, vehicles and had to borrow from friends and family.141

124. Detective Sgt Jenkins refused to discuss the new charges with Mr Maddison over the telephone.142 He indicated that he would probably be opposing Mr Maddison’s bail, and also tells Mr Maddison to ‘man up and come in…’ to which he replies, ‘why don’t you fucking man up and come fucking get me then.’’143 He also stated that Mr Maddison is getting ‘a little bit emotional’ and is carrying on like a ‘pork chop’.144

125. At one point during the conversation, Mr Maddison stated ‘…stop playing games youse know where I am. I’ve made it fucking easy enough for ya I left enough trails’.145

126. I accept the submission from Counsel Assisting that Mr Maddison was agitated during the telephone call and his level of agitation appeared to have been exacerbated by Detective Sgt Jenkins comments and tone. This is exemplified from the outset of the call, which commences with the following dialogue:146 JENKINS: Well whose faults that Ricky? As far as I’m … Well I think it’s yours Ricky you know if you’re not game enough to take responsibility for your own actions. [Pause] I’ve had a look at all of the case, the details in relation to you mate.

MADDISON: Right, right back from the start.

JENKINS: Yeah I have all the way back from the start. Okay, so … MADDISON: And you don’t think that I’ve been fucked.

JENKINS: No I don’t I think that you’ve probably gone, gone about your, the way you normally do you get agro like you are at the moment. I ah I am firmly of the opinion that you’ve committed all the offences that people have, have made allegations against you for doing. Now if you want to come in, if you wish to come in if you – MADDISON: UI one fucking UI.

JENKINS: if you wish to come in and speak to us then we will sort the matter out then.

127. On 6 June 2017, Detective Sgt Jenkins was interviewed as part of the Coronial investigation. He claimed that at times he aggravated Mr Maddison intentionally in order to keep him on the telephone so that he could be located by patrols.147 141 Ex G39, pg. 5 142 Ex G39, pg. 2, 7 and various 143 Ex G39, pg. 3 144 Ex G39, pg. 13 145 Ex G39, pg. 30 146 Ex G39, pg. 1 147 Ex B8.4, pg. 11-12; T7-31 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 21 of 82

Location of Mr Maddison and pursuit

128. While Mr Maddison was on the telephone to Sgt Jenkins, arrangements were being made for police to search phone boxes in the Toowoomba area. SC Brett Forte and SC Nielsen from Toowoomba TCS were among the units patrolling for Mr Maddison.148

129. At 1:44 pm, the Officer in Charge of Toowoomba TCS, Snr Sgt Scott Stahlhut called SERT and advised that Mr Maddison was speaking to Toowoomba police on the telephone. The plan was for Sgt Jenkins to negotiate with Mr Maddison and stall while police units attempted to find him. If a location was established for Mr Maddison, consideration was to be given to having SERT deploy to assist with his apprehension.149

130. The call between Mr Maddison and Sgt Jenkins ended at 1:51pm. Mr Maddison refused to hand himself into Police, stating several times that he was not ‘going to jail’.150 While Mr Maddison was on the phone, Snr Sgt Stahlhut contacted the Communications Coordinator (COMCO) Sgt Ian Douglas at Toowoomba Police Communications Centre, resulting in a number of other police crews conducting patrols of pay phones in the Toowoomba area.151

131. According to Sgt Douglas, such a call was ‘unusual’, and he was made aware that Mr Maddison was wanted for some serious offences which was ‘something playing on his mind’.152 At the inquest, he explained that this was part of his process of assessing and gaining an awareness of the situation and the high need to apprehend the offender.153 He was asked to organise resources to locate Mr Maddison by way of searches of phone boxes in the area.

132. In addition to the information provided by Snr Sgt Stahlhut, Sgt Douglas conducted his own searches of QPRIME to familiarise himself with Mr Maddison and was satisfied that he was a high-risk offender.154 He was receiving emails from Snr Sgt Stahlhut to this effect as well.155

133. At 1:52 pm, a Toowoomba General Duties unit (TW208) containing Constables Kaus and O’Connell observe Mr Maddison pull out from the curb at Mary Street in his brother’s Nissan Navara.156

134. A minute later, an intercept was attempted by TW208 on Campbell Street by activating lights and sirens.157 Mr Maddison failed to stop, and a slow speed pursuit commenced.158 During the course of the pursuit, Mr Maddison travelled down the Toowoomba Range towards Brisbane.159 148 Ex A5, pg. 6 149 Ex A7, pg. 13 & 14 150 Ex A7, pg. 14 151 Ex A5, pg. 6 152 T7-56 & 57; B31.5, pg. 8

153 T7-60 154 T7-58 155 Ex B31.5, pg. 9; T7-59 156 Ex A5, pg. 7 157 Ex A5, pg. 7 158 Ex A7, pg. 14 159 Ex A5, pg. 7 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 22 of 82

135. The Comco, Sgt Douglas authorised the pursuit to continue following the failed attempt to intercept. He acknowledged that he did not do this ‘lightly’ as there are many things that can go wrong with a pursuit.160 Sgt Jenkins had attended the Comms room at Snr Sgt Stahlhut’s direction. He told Sgt Douglas about the warnings and offences relating to Mr Maddison.161

136. Sgt Jenkins claimed his intention was to provide situational awareness to the Comco to conduct the necessary risk assessments.162 Sgt Douglas’ evidence at the inquest was that, while it was unusual, he saw no problem with Sgt Jenkins attending the communications room to relay information that Mr Maddison was dangerous and wanted for serious offences. He described this as ‘reliable intel’.163

137. It was well known by the police in pursuit that Mr Maddison may be armed, and it was thought he may have had access to a sawn-off shotgun.164

138. Early on, Sgt Douglas asked units with stingers proceed to locations on the likely route of Mr Maddison, which was thought to be the Warrego Highway.165

139. The pursuit continued down the Toowoomba Range at 1:56 pm. After around 30 seconds of travel down the Range, Mr Maddison pulled over and appeared to slow as if to stop his vehicle, before pulling back on to the road to continue.

140. At 1:57 pm, SC Brett Forte (traveling in TW753 with SC Nielsen) warned over the police radio to other following police units, ‘Just beware of firearms’.166 At 1:59 pm, the COMCO requested the availability of POLAIR.

141. At 2:00 pm, SERT was advised of the pursuit and began monitoring. The SERT Commander at the time was Inspector Timothy Partrige. At this time, TW208 was joined by TW753 (the vehicle driven by SC Forte) and were pursuing Mr Maddison.167

142. Mr Maddison continued to drive along the highway towards Ipswich. At 2:01 pm, SC Forte broadcast over the police radio ‘…be aware he was involved in firearms-related offences, so any takedown be very careful.’.168

143. At 2:03 pm, Sgt Douglas called POLAIR on Channel 711. At 2:04 pm, POLAIR advised they were waiting for the pilot and to conduct pre-flight checks. It was stated, ‘I am aware of a high-risk offender traveling east bound from Toowoomba, I believe it was channel 104…’169

144. At 2:04 pm, tyre deflation devices were deployed on the highway at Helidon Spa by unit TW269, which consisted of the Helidon General Duties team of Sgt Glen Thomas and SC Sam Ritchie.170 Mr Maddison avoided the stingers by driving off the road and continued driving along the highway.

160 T7-64 161 Ex A5, pg. 7; Ex B 8 (statement of Jenkins, pg. 4); T7-32

162 T7-33; T7-38 163 T7-61 & 62 164 Ex 8.4, pg. 35 165 Ex A5, pg. 8 166 Ex A5, pg. 8 167 Ex A5, pg. 9 168 Ex A7, pg. 15; Ex A5, pg. 9 169 Ex A5, pg. 9 170 Ex A7, pg. 15; Ex A5, pg. 9 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 23 of 82

145. During the pursuit other police units advised they were proceeding to other locations on the Warrego Highway to prepare for stinger deployment.171

146. Mr Maddison’s driving during the pursuit remained largely within the speed limit and was not overtly dangerous.172 Sgt Douglas stated that he was waiting for the vehicle to perform some dangerous act, such as drive on the wrong side of the road or at excessive speed. He would then have considered terminating the pursuit.173This did not occur in accordance with the sitreps being provided by the crews in pursuit.174

147. At 2:09 pm, SC Nielsen asked for POLAIR assistance via the radio network and was advised by communications that they were attempting to arrange POLAIR. The COMCO had called POLAIR to notify them of the pursuit at 2:03 pm. At 2:10 pm, SERT commenced deployment anticipating that they would be required to assist with the detainment of Mr Maddison at the end of the pursuit. 175

148. At 2:11 pm, Snr Sgt Stahlhut sent an email to the COMCO stating, ‘SERT – have been advised. They are monitoring the radio channel. Will advise if deploying to assist.’176

149. The Gatton Crew (TW270) with A/Sgt Scott Hill, Senior Constable Barlow and Constable Poulton set up a stinger deployment site at the intersection of the Warrego Highway and Phillips Road.177 Unfortunately, the deployment was unsuccessful as a civilian motorist had interfered. Mr Maddison continued to drive, avoiding the stingers at 2:12 pm.

150. At 2:12 pm, Sgt Douglas called the COMCO at Ipswich PCC to advise of the pursuit and that it was headed in that direction.178

151. Mr Maddison continued to drive onwards until at 2:14 pm he exited the highway driving across a dirt embankment to Forestry Road, Ringwood.179 Due to the nature of the terrain, the police sedans were unable to cross it. This left the four-wheel drive vehicles driven by SC Forte and SC Nielsen (lead vehicle), the Helidon crew (TW269) and the Gatton crew (TW270) to follow Mr Maddison.180

152. Mr Maddison continued to drive along Forestry Road before turning left into Wallers Road at 2:15pm.181 At this time, SC Forte’s vehicle (TW753) was approximately 20 to 30 metres behind Mr Maddison’s vehicle, with the Helidon crew approximately 60 metres back.182

153. TW269 indicated on the radio that ‘Wallers Road goes up to Logan’s Road up the top of Seventeen Mile Road at Helidon if we can get a vehicle at Seventeen Mile Road. That’s where it comes out. It’s a 4WD track and I don’t think any of our vehicles will get up there.’183 171 Ex A5, pg. 9

172 T7-64 173 Ex B31.5, pg. 15; T7-64

174 T7-64 175 Ex A5, pg. 9 176 Ex A5, pg. 10 177 Ex A5, pg. 10 178 Ex A5, pg. 10 179 Ex A5, pg. 10 180 Ex A7, pg. 15 181 Ex A7, pg. 15 182 Ex A5, pg. 11 183 Ex A5, pg. 12 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 24 of 82

154. The COMCO was not familiar with Wallers Road. After hearing that Mr Maddison had turned down Wallers Road, he tried to locate it on Atlas.184

155. At 2:17 pm, SC Forte and SC Nielsen followed Mr Maddison’s Navarra utility up Wallers Road through a rough and steep incline. Dash cam footage shows that the utility is at times difficult to sight as it is obscured by dust.185 There are ravines throughout the dirt road that make it difficult to navigate and cross.

156. At 2:18 pm, Mr Maddison stopped at the gated entry to the property on Wallers Road.

He can be seen on dash cam footage from the police vehicle exiting the utility before producing a Kris Corp KS30 automatic rifle. He almost immediately began firing a string of fully automatic gunfire directly at the police vehicle driven by SC Forte.

Still shot from dash cam of SC Forte and SC Nielsen’s vehicle

157. SC Forte reversed as rounds of ammunition penetrated the vehicle.186 Unfortunately, the vehicle ran up an embankment and rolled over on to the driver’s side, trapping SC Forte and SC Nielsen inside.

184 T7-65 185 Ex A7, pg. 15 186 Ex A7, pg. 15 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 25 of 82

158. Ballistics examination later found 47 spent ammunition casings at the location Mr Maddison shot at SC Forte and SC Nielsen.187 The analysis showed that Mr Maddison’s weapon carried a maximum 30 x 7.62 mm x 39 mm rounds in each magazine, which suggests that he changed magazines and continued to fire at the vehicle after it rolled.188

159. The Helidon vehicle (TW269) crew saw Mr Maddison fire his rifle and witnessed the rollover of SC Forte and SC Nielsen’s vehicle. They called for urgent assistance on the police radio and began reversing away from the threat.189 After reversing several hundred metres away from the scene the Helidon vehicle also ran up an embankment and rolled onto its side.190

160. The Gatton police vehicle had driven into the driveway of 220 Wallers Road when they heard gunshots. All Police at the scene described the gunshots as ‘fully automatic’ gunfire.’191

161. Still inside the TCS vehicle, SC Forte was unresponsive. SC Nielsen fired her police service pistol five times through the windscreen in response to the shots being fired at the vehicle by Mr Maddison.192 Ballistics examination subsequently found the TCS vehicle had been struck by 27 projectiles from Mr Maddison’s rifle, with six rounds penetrating the cabin.193 The bullbar of the Helidon vehicle was also found to have been struck with a round from Mr Maddison’s rifle.194

162. Mr Maddison then opened the closed gate and drove to the shed where he had been living. He parked the utility next to the shed before walking around it firing automatic bursts from his rifle into the bushland.195

163. QPS Helicopters POLAIR 1 and POLAIR 2 were notified and began proceeding at 2:27 pm from Archerfield utilising priority air travel.196

164. The automatic gunfire confused the officers who were attempting to recover SC Forte and SC Nielsen. They remained trapped in their vehicle. It was unclear where Mr Maddison was located. Gatton police officers arrived on foot and SC Hill assisted SC Nielsen from the vehicle by smashing the windscreen. Once outside the vehicle, first aid was provided by both officers to SC Forte.197 It was at this time, which was around 2:38 pm, that it was first recognised SC Forte had gunshot injuries.198

165. At 2:36 pm, Inspector Angus of the Police Communications Centre nominated Snr Sgt Rowland Browne as the on-scene Forward Commander (PFC), making other units aware that he was in proximal command.199 In doing so, Inspector Angus stated that:200 187 Ex A7, pg. 15 188 Ex A7, pg. 15 189 Ex A5, pg. 13 190 Ex A7, pg. 16 191 Ex A5, pg. 16 192 Ex A7, pg. 16; Ex A5, pg. 14 193 Ex A7, pg. 16; Ex A5, pg. 15 194 Ex A5, pg. 14 195 Ex A7, pg. 16 196 Ex A7, pg. 77 197 Ex A7, pg. 17; Ex A5, pg. 16 198 Ex A5, pg. 16 199 Ex A5, pg. 17 200 Ex A5, pg. 102 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 26 of 82

“I did that because there was some initial confusion there was no actual management occurring on the ground in relation to the incident. I was aware that Senior Sgt Browne, Rowland Browne who was the substantive officer-in-charge of the Gatton Police Station

• was present in the area as he had also attended the district performance review earlier ah in the morning earlier that day I should say. Via the Comco I nominated Senior Sgt Browne as the police forward commander. I then gave instructions for QAS to be mobilised to the scene, Queensland Fire and Emergency Services and all available units that we had in Toowoomba and within the Lockyer Valley to the job location.”

166. SC Barlow retrieved the Gatton vehicle, which was driven to the location of SC Forte.

He was placed inside and driven towards the Queensland Ambulance Service (QAS) staging area on Forestry Road.201 SCs Barlow, Nielsen and Hill remained at the location of the TCS vehicle on Wallers Road to cover any further threats posed by Mr Maddison.

167. At 2:40 pm, Constable Poulton drove SC Forte in a police vehicle along Wallers Road towards the QAS staging area. Automatic gunfire could be heard from time to time, with police unaware of Mr Maddison’s whereabouts.202

168. At 2:46 pm, Snr Sgt Browne advised that the inner cordon would tactically reposition to 169 Wallers Road until SERT arrive with more resources to allow for the inner cordon to be adjusted. Snr Sgt Browne acknowledged that he did not have sufficient resources or intelligence to place better-defined cordons. Mr Maddison’s whereabouts remained unknown and intermittent automatic gun fire could be heard.

169. At 2:47 pm, Constable Poulton stopped the police vehicle outside 50 Forestry Road.

The officers (Poulton and Thomas) removed SC Forte and placed him on ground before continuing CPR. The QAS arrived at 2:52 pm and took over more advanced medical care.203

170. At 2:50 pm, Inspector Sharee Cumming arrived at the scene where SC Forte was receiving CPR.204 At 2:56 pm, Inspector Cumming announced command as the PFC.

171. At 2:57 pm, POLAIR located the stronghold following which continuous video footage was recorded for the next 20 hours. Almost immediately after Mr Maddison was located by POLAIR, he fired shots at POLAIR in a burst of automatic gunfire.205

172. A life flight surgical team attended but were unable to revive SC Forte. He was pronounced deceased at 3:29 pm on 29 May 2017 by Dr Davidson.206

AUTOPSY FINDINGS – SC FORTE

173. On 30 May 2017, a full internal and external post-mortem examination was conducted by Pathologist Dr Beng Ong. Toxicological testing, a CT scan and review of the medical records were also carried out.207 201 Ex A7, pg. 17 202 Ex A7, pg. 18 203 Ex A7, pg. 18 204 Ex A5, pg. 17 205 Ex A7, pg. 6 206 Ex A7, pg. 17 207 Ex A4 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 27 of 82

174. A number of cluster injuries were observed, consisting of numerous superficial stipple abrasions and puncture wounds resulting from gunshots and shrapnel. These presented with complex entry wounds likely caused as a result of the gunshots encountering an intermediate target prior to entry. As such, the fragments, both shrapnel and projectile, had been directed in a dispersed fashion with a conical distribution.208 It was likely that SC Forte had sustained two or three gunshots.

175. The cause of death was found to be gunshot and shrapnel wounds to the body. The injuries observed as caused by the gunshots and shrapnel were extensive and would have caused extensive haemorrhage. It was noted that ‘information obtained indicated due to the initial critical situation, the QAS officers were unable to render aid immediately and this would have led to irreversible bleeding and complications.’209 Account of SC Catherine Nielsen

176. SC Nielsen was interviewed on a number of occasions following SC Forte’s death. SC Nielsen had been a member of the TCS for 15 years.

177. With respect to the pursuit of Mr Maddison, SC Nielsen stated that while following Mr Maddison on Wallers Road, there were a number of times when the dust was so thick, they could not see his vehicle.210 This was apparent from the dashcam footage. She indicated that she and SC Forte believed that Mr Maddison knew the area and was leading them somewhere.211 She stated:212 “When we turned down that road, just before it happened, minutes before it, seconds really, Brett said to me “It’s like he’s leading us somewhere” and I said, “I just thought the exact same thing.”

178. This suspicion that Mr Maddison was leading the police somewhere was not relayed to the Comco. He noted that would have been helpful information during the course of the pursuit.213

179. In terms of discussions with SC Forte about plans in pursuing Mr Maddison down Wallers Road, SC Nielsen stated: “Just directly in relation to Mr Maddison no we didn’t have discussions as such, we were both very aware. The tone in the car very much did change when he, probably after he took us down the embankment. I guess the seriousness of the possibility, the seriousness of things just did change in the car and we knew, we were very, we knew, we’re experienced police officers, so we were aware of any dangers you know being a high-risk offender.”

180. SC Nielsen was aware that Mr Maddison was classified as dangerous and may have had firearms.214 She acknowledged that he was considered a ‘high-risk’ offender.

208 Ex A4, pg. 15 209 Ex A4, pg. 17 210 Ex A5, pg. 67 211 Ex A5, pg. 95 212 Ex A5, pg. 95

213 T7-66 214 Ex A5, pg. 96 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 28 of 82

181. In terms of how the pursuit might end, SC Nielsen stated:215 “Well as we’re taught there’s nothing such as a low risk. Mr Maddison was already for me a high-risk offender absolutely. Now with pursuits, oh well it being obviously a pursuit, a pursuit as such is not that common with our policy. But normally I would imagine, you know, we would arrest him it would possibly you know something hands-on you know considering the use of force which I’m aware of the use of force model available, so I would have been aware of each of those options available to me as things progressed as the situation unfolded. I at one stage, because the nature of how we were in the office when the call was initially made and we all jumped out I didn’t have my recording device around my neck which I normally wear. So, as we were in the car I had said to Brett “Have you got your recording device on you?” I took that from him, and I remember I put it around my neck ready to turn it on thinking we would have to get out and address the situation. I would make sure it was on by the time we got out. But it didn’t eventuate that way.”

182. TW753 was only around 20 metres from Mr Maddison when he began to fire. SC Nielsen described that as:216 ‘We travelled along this road oh a handful of kilometres and then all of a sudden he stopped, Mr Maddison stopped his vehicle…He got out in a flash…and I just saw him raise his weapon…and then the next minute I heard was a number of shots, repetitive shots. They sounded quite tinny to me, we were thinking this is just an air rifle.’

183. SC Nielsen responded by sliding lower in her seat. She drew her pistol and fired a series of shots through the windscreen in the direction of Mr Maddison.217 She was in fear for her life and SC Forte’s. By this time, the car had tipped and was on its side. She was aware SC Forte had been injured. It was unclear where Mr Maddison was located. She called for urgent assistance.

184. While SC Nielsen subsequently managed to get out of the police vehicle, she was unable to remove SC Forte. She recalled SC Hill and other officers approaching on foot to assist. She smashed the windscreen to try and allow SC Forte to be removed. He was dragged from the vehicle by SC Hill and herself. He was breathing at the time, and they continued to speak to him.

185. The Gatton vehicle was retrieved to transport SC Forte, while SC Nielsen continued to monitor him. Shots were still being fired. SC Forte’s load bearing vest was removed, and his complexion changed dramatically making it clear he was badly injured. Constable Poulton transported SC Forte while SC Nielsen remained at the scene.

186. SC Nielsen told the inquest that she knew Mr Maddison was a priority offender for TCS.218 She explained there was a separate part of TCS, known as the Tactical Action Team, who were plain clothes officers responsible for looking for offenders. Other TCS officers may be asked to assist in the execution of warrants and the like.219 215 Ex A5, pg. 96 & 97 216 Ex A5, pg. 67 217 Ex A5, pg. 67

218 T4-6 219 T4-7 & 8 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 29 of 82

187. In terms of this division, SC Nielsen claimed that TAT worked differently, running their own ‘rock show’ compared to TCS, specifically with respect to complying with legislation and information sharing, noting that ‘knowledge is power’.220 She was not surprised that SC Forte regarded the B-Team as being kept in the dark . She also asserted that SC Thaler was using the Wickr application to communicate with unregistered human sources.

188. SC Nielsen also said that in the lead up to SC Forte’s death, Snr Sgt Stahlhut spoke about his previous interactions with Mr Maddison from around 10 years earlier. This was after Mr Maddison became a significant target of the TCS.

189. When SC Nielsen was asked about the conversation, which surrounded the radio transmission made by SC Forte during which he notified other units that Mr Maddison was involved in ‘firearms related offences’ and to be ‘very careful’, SC Nielsen stated the following:221 Well, as I say, Bretty had a bit more knowledge obviously Susie in relation to more of the ins and outs of what had happened, so we were aware that on that particular job there was a firearm used.

190. With respect to the decision to continue following Mr Maddison down Wallers Road, SC Nielsen provided the following evidence:

• She was not familiar with Wallers Road and had never travelled along that road before the pursuit.222 She had no knowledge of reports of automatic weapons fire on Wallers Road. If she did this would have impacted her decision making. It may have also affected the Comco’s decision-making, as he was known to take a conservative approach.

• She acknowledged that it was known it was a ‘high-risk’ situation, given the terrain, visibility, and dangerous offender. However, she described it as ‘our job to do.’223 For this reason, based on the information she had as the senior officer, she decided not to terminate the pursuit.224

191. SC Nielsen described at the inquest that how she felt she had been “shit-canned” in the TCS after SC Forte’s death for asking questions and was threatened with 466s (official complaints).

Previous knowledge of Mr Maddison by Police

192. Throughout the interviews with officers involved in the pursuit of Mr Maddison, it was acknowledged that he was a high-risk dangerous offender, who was wanted on four warrants and had evaded police for some time. It was understood that he may have had access to weapons, particularly after he threatened Ms B with the pistol at Penderests Road. However, it was unknown that he had access to automatic weapons.

220 T4-28 221 T4-14 222 T4-16 223 T4-17 & 18 224 T4-18 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 30 of 82

193. In the context of Mr Maddison’s history, a number of officers were asked about the risk assessment conducted in pursuing Mr Maddison and continuing to follow him down Wallers Road. It seems a number anticipated that a confrontation or foot chase would eventuate.225 They were all acutely aware that he was dangerous.

194. In addition, a subsequent intelligence search of information available to QPS identified the following entries with respect to Mr Maddison:

• Highfields’s Tavern incident 22 July 2007 Snr Sgt Stahlhut had attended the tavern on his day off and observed a person he knew to be the subject of an investigation. This person was in company with Ricky Maddison, who introduced himself to Snr Sgt Stahlhut and there was a relatively brief discussion in the men’s bathroom. An intelligence report was submitted outlining this interaction. Snr Sgt Stahlhut had no knowledge of Mr Maddison at this time.

• Incident at Snr Sgt Stahlhut’s residence There was an encounter many years ago whereby in the early hours of the morning a group of persons attended Snr Sgt Stahlhut’s residence, one with a piece of chain, before realizing they were at the wrong address. Mr Maddison was not involved in this incident. Snr Sgt Stahlhut denied that he had ever suggested this incident involved Mr Maddison or his associates.226

• QPRIME occurrence – 24th August 2007 A QPRIME occurrence had been created on this date with respect to a Ricky Matterson following a conversation with a registered human source, who provided information about a number of other persons.227 With respect to Ricky Matterson, it was reported that he had a semi-automatic weapon, which was capable of being converted to automatic fire. Snr Sgt Stahlhut asserted during the inquest that he never made the link between Ricky Matterson and Ricky Maddison.228 The source was subsequently interviewed, and a search conducted, during which no weapons were located.229 Det Snr Sgt Hinshelwood’s evidence during the inquest was that this information was only located after a specialist intelligence officer was engaged to consider information for the purpose of the coronial investigation.

195. In relation to the incident at the Highfields Tavern, Snr Sgt Stahlhut told the inquest that he encountered another male who was facing charges with a man who identified himself as Rick in the toilets. He claimed both were polite and he then returned to the bar. He later completed an Intelligence Report.

196. With respect to the incident at his residence, Snr Sgt Stahlhut said that the offenders were at the wrong address. Mr Maddison was not involved in this incident. He also asserted that he had no idea when the August 2007 QPrime occurrence was linked to Mr Maddison, although he was the author of that occurrence. He also asserted that Mr Maddison was not a target of Operation Delta Rosetta.

225 Ex A5, pg. 97 – 99 various

226 T6-4 227 Ex C279

228 T6-5 229 Ex A5.1, pg. 14 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 31 of 82

197. Det Snr Sgt Hinshelwood’s evidence was that, based on her assessment of the information of what was known or could have been known by TCS or any other officers about Mr Maddison and the weaponry he had available at the time of the pursuit, there was no information available, which would or should have enabled a link to be made between Mr Maddison and automatic weapons.230

POLICE RESPONSE TO MADDISON DURING SEIGE

198. At 2:48 pm, POLAIR advised that they were at the incident location and scanning. SERT arrived in the area of operation as well and were liaising with POLAIR. At 3:04 pm, SERT Commander, Inspector Partrige, arrived at the PFCP.231

230 T1-25, 26 231 Ex A7, pg. 18 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 32 of 82

199. At 3:10 pm, Snr Sgt Browne confirmed that POLAIR had visual containment and would be able to advise if Mr Maddison left the stronghold. There was nothing stopping Mr Maddison leaving the stronghold as officers were only placed at obvious points of egress from the area. This was the first sighting of Mr Maddison since SC Forte had been shot and provided greater situational awareness for the responding officers.

200. At 3:15 pm, Inspector Cumming arrived at the PFCP located at the intersection of Forestry Road and Alviso Road, Ringwood.232

201. Neighbours were initially advised to shelter. After the inner cordon was established an ‘emergency situation’ was declared under the Public Safety Preservation Act 1986 and they were safely evacuated.233

202. At 3:19 pm, SERT arrived at the inner cordon on Wallers Road having been provided with the coordinates from POLAIR at 3:13 pm. While entering the property, a Kris Corp 30 banana magazine was found by the front gate.234

203. At 3:38 pm, Snr Sgt Browne asked negotiators to attend, and he began to work on the outer cordon. POLAIR confirmed that Mr Maddison was alone at the stronghold.

204. SERT began to establish isolation and containment of Mr Maddison. At 3:35 pm, the SERT mission was developed by the SERT Commander, in conjunction with the PFC as ‘isolate and contain the stronghold’.235 To achieve this objective, two marksman pairings and two entry teams were positioned on top of the driveway of the stronghold with designated roles to effect containment of Mr Maddison. The teams were directed that if Mr Maddison attempted to breach the inner cordon he was to be intercepted and secured. At the time, Mr Maddison was still walking around bushland firing randomly at POLAIR and into the scrub.

205. By 3:38 pm, Mr Maddison had discharged another burst of fully automatic gunfire. He had fired at POLAIR or into bushland 10 times (excluding the shots fired at SC Forte and SC Nielsen). He was continuing to fire into bushland at random intervals and was posing an active and ongoing threat to approaching SERT operators.

206. By 4:02 pm, SERT had effected some containment of Mr Maddison, establishing an inner cordon approximately 50 metres from the driveway of the shed.

207. At 4:15 pm, negotiators, Sgt Ian Stephens followed by PCC Dale Hanson arrived at the PFCP. Negotiations initially commenced by way of the Lenco Armoured Vehicle (Bombcat) using a loudspeaker until a mobile telephone was able to be delivered to the stronghold. From this point onwards, various police officers took the lead as ‘primary negotiator’ using the telephone.

208. At 4:40 pm, SERT began to move negotiators forward in the armoured Bombcat to attempt communications with Mr Maddison by way of an audio speaker. At the same time, the SERT Commanders held a briefing with Inspector Cumming at the FCP. SERT then assumed command of the inner cordon and the PFC maintained overall command of the incident.

232 Ex A7, pg. 19 233 Ex A7, pg. 20 234 Ex A7, pg. 19 235 Ex A7, pg. 19 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 33 of 82

209. Inspector Partrige established plans based around options open to Mr Maddison and the stronghold in conjunction with Inspector Cumming. The plans evolved and were reviewed as the situation progressed.

210. At 5:05 pm, due to failing light and the need to be closer to the stronghold, the SERT mission became ‘to shrink containment and establish negotiations via Bearcat’. It was unknown whether Mr Maddison had any hostages.

211. At 5:15 pm, SERT and negotiators moved closer in the Bombcat to be able to communicate properly with Mr Maddison.

212. At 5:24 pm, Mr Maddison was outside the stronghold when he fired further rounds into bushland. He was yelling. However, SERT operators were unable to discern what he was saying. It was suspected he was responding to transmissions made via the Bombcat.

213. The initial negotiations, which were mostly one way via loudspeaker from the Bombcat, centred on containing Mr Maddison within the stronghold and trying to stop him from indiscriminately firing his weapon.236 This was difficult as he was only able to shout or use hand signals to communicate with the negotiators.

214. At 5:28 pm, Mr Maddison fired twice towards the Bombcat as it was moving towards the stronghold on the driveway. The rounds were heard by officers inside the vehicle to have hit. The intent was to establish a suitable distance, which would allow negotiators to effectively communicate with Mr Maddison, and to have visibility of his actions. At this time, he was yelling ‘Fuck off’ at police.237 The Bombcat withdrew slightly down the driveway.238

215. At 5:35 pm, Mr Maddison fired rounds for the 20th time across the front of the stronghold.

This was the last time Mr Maddison fired his weapon until 11:05 am the following morning.

216. At 6:07 pm, PFC Inspector Cumming approved a plan to deliver a mobile telephone by robot to the stronghold.239

217. At 7:41 pm, SERT operators were able to deliver a mobile telephone to Mr Maddison via the robot, which enabled two-way negotiations.

218. At 7:45 pm, Police negotiator, DSC Reedy telephoned and spoke to Mr Maddison. Over the next few hours discussions were had, which included the death of SC Forte. Mr Maddison appeared shocked to learn of the officer’s death and initially apologised for killing him stating that this was not his intent. The following is an excerpt of the conversation: Maddison: “I don’t know what to say about this afternoon I was cornered they drew on me um really, I don’t have the words I’m sorry I’m…mate if you knew me and there wasn’t a situation I’m not this person they’re making me out.’ 236 Ex A7, pg. 20 237 Ex A7, pg. 21 238 Ex A7, pg. 63 239 Ex A7, pg. 21 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 34 of 82

219. At 8:19 pm, SERT learnt via communications with the negotiator that Mr Maddison had two motorcycles within the stronghold. A third motorcycle was observed on the front porch. Mr Maddison had advised that he had two sub-machine guns and one fully automatic machine gun with a quantity of armour piercing rounds.240

220. In terms of his surrender, Mr Maddison repeatedly demanded that Detective Sgt Andrew Lowe and Ms M be brought to the stronghold so that he could assault them following which he would surrender.241 Obviously, such demands were unreasonable and were refused.

221. Negotiations continued over several hours and focused on Mr Maddison’s allegations that Ms B was an unreliable witness who had been unfaithful to him, as well as the recommencement of charges against him by DSC Lowe. Negotiators tried to develop rapport with him by using “long brackets” negotiations. They repeatedly asked him to come out and surrender.

222. At 11:30 pm, Inspector Steve Angus became the PFC. Between midnight and 12:40 am, a formal surrender plan was repeatedly communicated to Mr Maddison. The block of negotiations ended when Mr Maddison advised that he could drive out of the stronghold if he wished. A new negotiator was put in place.

223. At around 1:00 am on 30 May 2017, Mr Maddison became irate and demanded that the Bombcat withdraw, threatening to shoot out the lights of the vehicle. SERT then withdrew a short distance.

224. At 1:40 am, Mr Maddison became paranoid as he believed someone was moving around the stronghold. POLAIR confirmed that this was not the case. He continued to demand that Toowoomba Police and Ms B be present so that he could fight them. His requests were denied.242

225. At 2:04 am, Mr Maddison was communicating with negotiators when he said that his only options were going to jail or ‘being dead’. Police negotiator, Snr Sgt McCullough, established that Mr Maddison was not considering suicide. Instead, he would provoke police to shoot him.

226. At 3:36 am, Inspector Barry Smith became the primary negotiator. Surrender plans continued to be communicated to Mr Maddison, whose mood fluctuated over the next few hours.

227. At around 4:09 am, Mr Maddison told Inspector Smith that he was considering coming out. Negotiations were suspended while he contemplated his options. Negotiations resumed at 4:30 am, when Mr Maddison was advised that SERT staff would commence change over. He commented that it may be a good time to leave the stronghold. To maintain the integrity of the stronghold, the staff changeover was slowed.243

228. At 5:13 am, Mr Maddison advised negotiators he may try to leave with his motorcycle.

This alarmed SERT operators and negotiators.

229. At 6:00 am, Inspector Cumming returned to the PFCP and commenced briefings and changeover with Inspector Angus.

240 Ex A7, pg. 21 241 Ex A7, pg. 21 242 Ex A7, pg. 22 243 Ex A7, pg. 22 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 35 of 82

230. At 6:30 am, while talking to police negotiator Inspector Smith, Mr Maddison exited the stronghold via the rear door carrying his Kris Corp 30 rifle and the other SKK slung across his back with a backpack. He was asking whether SERT operators were going to shoot him if he walked around the stronghold. While outside, Mr Maddison repeatedly yelled at the Bombcat, ‘if you don’t shoot at me, I won’t shoot at you’. He was asked to put his weapons down and not engage with SERT.

231. At 7:15 am, Inspector Wright, the new SERT Commander assumed control of the inner cordon with Inspector Cumming signing a Handover Form. A new EA plan and Surrender Plan were adopted and modified. At the same time, the sound of a motorcycle starting up could be heard in the stronghold. This raised concern about the risk associated with Mr Maddison having a means of escaping the stronghold via vehicle.

232. At 7:45 am, the SERT mission was reiterated to be ‘contain and isolate the POI to the stronghold and support negotiations.’ Mr Maddison appeared to be agitated by the presence of SERT operators in the inner cordon, focusing on the operators who were looking in and out of the Bombcat. He threatened to shoot these operators, who were performing observations, and to ‘cut in half’ those he could see in the bush with his automatic rifle.

233. At 8:00 am, Emergency Action Commander, SERT Operator 44 advised that all surrender plans had been communicated to the SERT operators. Negotiations at this time were then to focus on having Mr Maddison surrender.244

234. At 8:25 am, SERT operators moved the Titan robot to the back door of the stronghold to limit Mr Maddison’s options of escaping the stronghold. It remained in this position until 9:11 am.

235. At 9:00 am, PCSC Nevell commenced as the primary negotiator with Maddison. It was thought that a female may assist to shift the direction of the negotiation. Snr Sgt Sean McKay, became the new negotiator team leader.

Decision to disable vehicles

236. At 9:05 am, SERT began to consider options to disable the vehicles available to Mr Maddison, namely the Navara and motorcycle, using the robot. At the time, Mr Maddison’s demeanour was calm, and he was engaging with PCSC Nevell.

237. At 9:09 am, Inspector Cumming approved the plan, which involved SERT leaving the vehicles undamaged if Mr Maddison surrendered.

238. At 9:14 am, the robot was positioned off the front porch of the stronghold at which time Mr Maddison was yelling ‘don’t touch that fucking bike’. Negotiators offered Mr Maddison the option of leaving the motorbike untouched if he surrendered. He became agitated, stating that it was the last thing he owned and if it was damaged, he would come after them.245

239. The robot remained in position until 9:40 am as negotiations continued. Mr Maddison suggested during this time that they were trying to antagonise him.

244 Ex A7, pg. 23 245 Ex A7, pg. 24 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 36 of 82

240. At 10:00 am, the robot was positioned to deflate the first tyre of the Navara. Mr Maddison was given the opportunity to surrender. He refused to do so before the tyre was deflated.

241. At 10:15 am, the robot was withdrawn without deflating the tyre to refit tools, while the negotiations continued. Mr Maddison indicated that he was tired.

242. At 10:21 am, the robot was positioned to deflate the second tyre of the Navara, with Mr Maddison again being given the opportunity to surrender first. The tyre was deflated at 10:23 am. The robot subsequently withdrew to allow for further negotiations.

243. At 10:27 am, negotiations were suspended. This was the last telephone contact police had with Mr Maddison. He seemed to believe that police were trying to lure him from the stronghold so that he could be shot despite reassurances that this would not occur.

244. At 10:41 am, negotiations with Mr Maddison recommenced from the Bombcat, asking that he surrender before his motorcycle was disabled. The reason the negotiations were moved to the Bombcat was that PCSC Nevell was off site, and unable to see Mr Maddison’s reactions or the movement of the robot. It was thought more tailored responses could be provided from the Bombcat.

Mr Maddison’s death

245. At 11:04 am, the robot was held at the top of the driveway 25 m from the stronghold and Mr Maddison emerged from the rear of the stronghold. He was carrying the Kris Corp rifle in his hand, with the Chinese State Arsenal SKK over his shoulder. He moved 15 metres away from the stronghold before taking aim and firing the Kris Corp rifle towards the SERT light armoured vehicles. He subsequently moved sideways while changing the magazine of the weapon before reloading a second magazine.

246. The rounds fired by Mr Maddison hit the light armoured vehicle containing SERT operators 123 and 129. SERT Operator 44 was outside the vehicle and SERT Operator 113 was in the Bombcat turret. The Bombcat and robot were subsequently found to have sustained some damage, which may have been from this event. The evidence supports that Mr Maddison fired a full magazine at SERT operators located on the stronghold driveway.246

247. POLAIR footage shows Mr Maddison react and double over after being shot by SERT Operator 44 or 113. He continued to run into bushland.

248. At 11:05 am, Mr Maddison lay prone on the ground and appeared to be conducting a magazine change. After seven seconds, he began to run towards the marksmen pairing of SERT Operators 175 and 177 while carrying his two firearms.247

249. Mr Maddison was then engaged by SERT Operators 177 and 175, who simultaneously fired their weapons at him to stop the advancing threat. Mr Maddison was hit in the chest. Tactical first aid was rendered to Mr Maddison by SERT Operators and the QAS paramedics, who were on standby, were called to the scene.

250. Mr Maddison was declared life extinct at 11:16 am on 30 May 2017.248 246 Ex A7, pg. 86 247 Ex A7, pg. 26 248 Ex A7, pg. 26 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 37 of 82

AUTOPSY FINDINGS - MADDISON

251. On 31 May 2017, an external and full internal post-mortem examination was conducted by Pathologist, Dr Nathan Milne. Toxicological testing and CT scanning was also carried out.249

252. The mechanism of death was found to be a singular gunshot wound, involving the chest and abdominal cavities, which caused significant injuries. The entry wound was found to be in the left chest with an exit wound in the right side of the back. It was noted that the entry wound had features of a distant range of fire. A second gunshot wound was also noted through the left posterior shoulder exiting the left upper back. However, this only caused soft tissue damage in the left back region.

253. Toxicology testing of blood samples taken detected methylamphetamine at a level potentially in the lethal range. However, it was noted that regular users of such drugs can survive at significantly higher levels. Diazepam, codeine, celecoxib (antiinflammatory) and duloxetine (antidepressant) were also detected at therapeutic levels or below.

254. The cause of death was a gunshot wound to the chest and abdomen.

POLICE INVESTIGATION COMMENCEMENT OF THE ESC INVESTIGATION

255. Inspector Cumming was the first commissioned officer at the scene and assumed the PFC role. She had returned to this role at the time Mr Maddison was killed. By that time, ESC were conducting parallel investigations into the death of SC Forte with the Homicide Unit. ESC was notified of Mr Maddison’s death at 11:10 am on 30 May 2017.

The ESC then assumed command of the overall investigation into both matters.

256. Following Mr Maddison’s death, a crime scene was established at 162 Wallers Road.

Movements throughout the scene were recorded in a crime scene log.250 A crime scene warrant was later obtained.

257. The Crime and Corruption Commission (CCC) was notified of the deaths and attended the scene.251 I also attend the scene on the afternoon of 30 May 2017.

258. A door knock of the area was conducted in relation to the death of SC Forte. Numerous witness statements confirmed shots had been heard being fired on 29 May 2017.252

259. Critical incident testing was conducted of the officers who fired their weapons, namely SERT Operators 44, 113, 175 and 177, as well as Incident Commanders - the SERT tactical commander, Operator 35, SERT Commander, Inspector Wright, PFC’s Inspector Cumming and Inspector Wright.253 Police negotiators, Sgt Adam Reedy and SC Shane Gleeson, who were speaking to Mr Maddison at the time of the shooting, were also tested. All police officers returned negative results for drugs and alcohol.

249 Ex A5 250 Ex A7, pg. 65 251 Ex A7, pg. 66 252 Ex A7, pg. 66 253 Ex A7, pg. 66 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 38 of 82

260. Between 3 June 2017 and 5 June 2017, a search of the property of Lot 39/162 Wallers Road was conducted by QPS Search and Rescue Marine Co-ordinator, SC Clinton Shearer utilising up to 60 SES and police staff. There was nothing of significance located on other parts of the property.254 Goodbye note from Mr Maddison located in Navara

261. On 2 June 2017, a QPS Forensic Search Team searched the shed, vehicles and surrounds. A handwritten letter was located in the glovebox of the Nissan Navara.

Fingerprints belonging to Mr Maddison were subsequently found on the letter.255

262. The note appeared to be a suicide note addressed to Mr Maddison’s family. It states the following:

• Please don’t be sad I wasn’t meant to grow old…

• Last 21 months has taken its toll on me financially physically and as much as I hate to admit it mentally!!

• So turns out I couldn’t live either way - But will die happy knowing despite losing everything.

• But I lost my confidence dignity and most of all ‘pride’

• So I guess they broke me…SHE broke me

• Once again please don’t be sad. I had a hell of a life and remember me how I was please. Not this last shadow of the man and brother you knew.

• See you all on the next level

• Coppas – told you not to push me.

263. Mr Maddison also wished his family well, apologised for not being a part of future family events and told his family how much he loved and values them.

264. DSC Buxton concluded the note was written during the siege after Mr Maddison had killed SC Forte and before the tyres of the Navara were deflated.256

265. A search of the stronghold also located a sign in the rear bedroom with a message written on a plastic tub lid, which stated ‘send cops, not army. TWMB CIB I have no beef with the Army’.257

266. It was unknown when the sign was written, and it was not presented during negotiations.

Motorcycles in stronghold

267. A search of the stronghold located four motorcycles, one of which, a Black Kawasaki ZX-14R had been stolen from a residence during a break and enter on 13 January 2017.258

268. The motorcycle had been fitted with false Queensland registration plates with the original plate cut in half and placed between two bricks at the rear of the shed.

269. It was suspected Mr Maddison stole the motorcycle or had received it as stolen goods.

254 Ex A7, pg. 67 255 Ex A7, pg. 67; Ex F37 (photos of note) 256 Ex A7, pg. 68 257 Ex A7, pg. 70 258 Ex A7, pg. 71 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 39 of 82

Uniden Camera in Navara

270. A Uniden Camera was found in the Navara that had been removed from a tree above the front gate of the stronghold property. It is unclear when the camera was removed. It was subsequently found to be a dummy camera as it didn’t have the requisite power supply. It was suggested by DSC Buxton that the camera is significant ‘in that its purpose was to keep people out of the property’.259 Parabolic Microphone

271. A parabolic microphone, used to amplify sounds from a distance, was located in the stronghold. Mr Maddison had been observed with the microphone during the siege at 7:42 pm on 29 May 2017 during the delivery of the negotiators’ telephone.260 He may have been using it to monitor the conversations of police during the siege.

Firearms and ammunition located in the stronghold

272. The following weapons were subsequently located at the property:261

• Six Corp KS-30 – Category R (fully auto) - with Mr Maddison when killed

• Norinco Type 56 - Category D (semi-auto) – stronghold bedroom

• Chinese State Factory 26, Type 56 – Category D – on Mr Maddison

• Rossi Model 62SA – Category A (pump action) – stronghold front door

• Mauser 1938 Swedish short rifle – Category B (Bolt action) – stronghold front door

• Stirling Model 110 – Category H bolt action - stronghold on a front chair in holster

• Richards Antique Black powder pistol – Antique – stronghold on table

273. A large amount of unused Norinco 7.62 mm x 39 mm full metal jacketed steel core round ammunition was located in the stronghold, with an estimated 500 rounds remaining within boxes. A number of empty boxes were also discovered.262 Ammunition for the .22 calibre weapon was also found in the stronghold.

274. Mr Maddison had 385 rounds in the weapons he was holding and in his pockets at the location he was shot.

Dangerous Drugs

275. During the search of the stronghold, glass pipes for smoking amphetamines and other drug-related items were located together with a bag of cannabis.263 An examination of these items by Detective Sgt Galovic from the Synthetic Drug Operations Unit concluded that possession of the condenser unit and distillation head could constitute offences under s 9A of the Drugs Misuse Act. Possession of the glass pipe used for smoking amphetamine could also be an offence under s10(2) of Act.264 259 Ex A7, pg. 73 260 Ex A7, pg. 74 261 Ex A7, pg. 75 262 Ex A7, pg. 75 & 76 263 Ex A7, pg. 76 264 Ex A7, pg. 77 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 40 of 82

Mr Maddison’s Laptop computer

276. An Acer laptop was located within the stronghold. In the computer’s recycle bin were images from the QPS Cuddeback Camera and a large number of copies of messages from Ms B’s mobile telephone. 265 The images from the camera captured Mr Maddison locating the device.

Witness interviews

277. Extensive interviews and witness statements were conducted with various civilian and police witnesses involved in the events on 29 and 30 May 2017, as well as prior dealings with Mr Maddison and the operational response following the events.

Interviews with SERT Operators

278. Walk through interviews were conducted with each of the SERT Operators involved in the siege.266 Each of the Operators was separated following Mr Maddison’s death and given a direction not to discuss the incident.267

279. The plans for the engagement and negotiation with Mr Maddison for which SERT were involved correlate with the accounts provided by the Operators. The Operators who engaged with Mr Maddison in the lead up to his death both stated that they were fearful for their lives and there were no other suitable use of force options available given the situation.

Negotiations with Mr Maddison

280. Police negotiators engaged with Mr Maddison from 5:20 pm on 29 May 2017 until the time he was shot. In an attempt to have him agree to exit the stronghold and surrender to police, he was asked to do so no less than 85 times.268 While negotiations were initially via the loudspeaker from the Bombcat, a mobile telephone was delivered to the stronghold at 7:45 pm.

281. Negotiations from the Bombcat were not recorded due to the change in the usual deployment of the Bearcat as the primary vehicle for SERT.269 However, a recording made by SERT Operator 153 using a mobile phone along with negotiator notes, SERT log entries, and interviews with negotiators, corroborate that Mr Maddison was asked to surrender by negotiators in the Bombcat several times.

282. Mr Maddison was reassured that his complaints about the charges involving Ms B, primarily directed towards the Toowoomba police, would be reviewed and officers from Ethical Standards Command were present to undertake this duty.270

283. Negotiation strategies varied throughout the engagement with Mr Maddison, initially focussing on building rapport by long brackets of conversation. This strategy changed on the morning of 30 May 2017 when PCSC Nevell commenced as the primary negotiator and negotiation brackets were reduced.271 265 Ex A7, pg. 77 266 Ex A7, pg. 26 – 51 precis; 267 Ex A7, pg. 66 268 Ex A7, pg. 64 269 Ex A7, pg. 64 270 Ex A7, pg. 64 271 Ex A7, pg. 64 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 41 of 82

284. The negotiations with Mr Maddison were protracted and different primary negotiators and strategies were engaged to speak to him over the telephone and via the Bombcat.272 He was provided with many opportunities to surrender peacefully, with plans being proposed. He indicated on several occasions that he did not intend to leave the stronghold. Negotiators made all attempts to keep him calm.

285. DSS Buxton submitted that the negotiations were appropriate relative to the incident and the best method to resolve the situation safely. I accept that conclusion.

Statement of Senior Sgt Pamela Leech – POLAIR OIC

286. Snr Sgt Pamela Leech, the OIC of POLAIR Queensland, Specialist Services Group, Operations Support Command provided a statement commenting on the footage captured of the siege.273

287. Each of the helicopters was fitted with 380 HD FLIR cameras, which provide various sensors or camera modes that can be utilised dependent on job requirements.274 The footage is retained and provides details about the helicopter’s GPS, speed, direction and altitude, as well as the location and direction of the camera.275

288. Officer Leech outlined the procedure to be followed before POLAIR can commence operation, including pre-flight checks and requirements.

289. Having reviewed the footage of the siege, Officer Leech noted:276

• Helicopter was reversed out of the hanger at 2:22 pm.

• Departed base at 2:26 pm headed for Gatton.

• Over 21-hour siege POLAIR provided aerial support to all crews on ground via radio and video footage.

290. In October 2017, following the incident, there was a transition to the use of the SLSQ Safety Management Reporting System within the Air Maestro software, which enabled the live recording to be kept and POLAIR OIC, TFO and pilots with visibility over any reported issues and subsequent rectification actions.277 Ballistics Examination

291. Following the incident, an examination of the ballistic evidence was conducted by Sgt’s Ashley Huth, Michael Clark and Brett Meara.

292. All weapons belonging to the SERT operators were examined and tested by Sgt Huth.

Each weapon fired satisfactorily with test shots and the corresponding casings located at the stronghold scene matched.278 272 Ex A7, pg. 157 273 Ex B50 274 Ex C50, [4] 275 Ex C50, [8] & [9] 276 Ex C50, [23] onwards 277 Ex C50, [50] 278 Ex A7, pg. 79 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 42 of 82

293. Relevantly, the further ballistics examinations revealed metal fragments removed from Mr Maddison’s chest cavity could not be excluded from having been discharged by SERT Operator 175.279

294. Mr Maddison’s Kris Corp 30 Rifle was modified to make it automatic. In factory production, this weapon should only discharge one round with each trigger pull. The trigger mechanism was found to have been modified with an extension added to the ‘sear’.280 When tested at the range, the weapon was found to discharge automatically (30 rounds for one trigger pull) and could also produce short bursts of automatic fire.281 As the weapon had been modified, it was found to experience recurring stoppages as a result of the incorrect feeding of the ammunition, which would cause it to stop firing.282 The modification made, which was found to be done quite simply, rendered the weapon a ‘Category R’ rifle, possession of which is an offence under the Weapons Act 1990.283

295. An examination of the 28 casings located in areas where Mr Maddison had fired at SERT found that 27 of them had been discharged from his Kris Corp KS-30 rifle.284

REVIEWS OF THE INCIDENT

296. Following the deaths of SC Forte and Mr Maddison, internal reviews were conducted by the QPS about components of the circumstances surrounding the incident.

GATTON POLICE INVESTIGATION INTO REPORTS OF AUTOMATIC GUNFIRE

297. Between February 2017 and May 2017, there were repeated calls by concerned Ringwood residents to the Gatton Police regarding automatic gunfire heard in the area.

Investigations had commenced, which included the monitoring of areas close to Mr Maddison’s stronghold.285

298. As noted above, as part of this investigation, on 17 May 2017, a Cuddeback Camera was placed in a tree opposite the driveway of the stronghold by Snr Sgt Browne, the OIC of Gatton Police and SC Brad Smart. The camera was programmed to take short videos when the motion was detected and corresponding still images. The camera carried the engraving ‘Gatton Police’. Police had gained the owner’s consent to place the camera on 220 Wallers Road.

299. A/Sgt Smart told the inquest that two weeks before the camera was installed, he had gone up Wallers Road and spoke with a male who asked him if he was “there about cattle or gunfire”. He told A/Sgt Smart that the gunfire was coming from next door which was a property with a shed or weekender on it. A/Sgt Smart was aware by this time that Adam Byatt was associated with the property, and it was likely he was responsible for the gunfire.

279 Ex A7, pg. 81; Ex B39 280 Ex A7, pg. 81; Ex B39 281 Ex A7, pg. 82; Ex B39 282 Ex A7, pg. 82; Ex B39 283 Ex A7, pg. 82; Ex B39 284 Ex A7, pg. 85 285 Ex A7, pg. 72; Ex C28 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 43 of 82

300. His plan was to leave the camera in the tree for two weeks and swap the SD card on 20 May 2017. When he went to retrieve the SD card on 20 May 2017, he saw a male in a white vehicle so decided not to retrieve the card. A/Sgt Smart agreed that reports of automatic gunfire were extremely unusual, and that this information had been siloed in Gatton station. He did not think there was anything sinister about the gunfire as it had gone on for months.

301. A video timeline of the Cuddeback camera footage and material shows the movements of Mr Byatt and Mr Maddison’s vehicle near the property as well as SC Thaler. It also shows when Mr Maddison located the camera on 26 May 2017. He subsequently relocated the camera placing it inside the stronghold. On the date of the siege, positioning of SERT’s AV can be seen from camera.

302. After he located SC Thaler’s intelligence report from 18 May 2017, SC Smart sent an email to him on 22 May 2017 advising of the reports of automatic gunfire in the region, which they had narrowed down to the property owned by the Byatt family.286 SC Thaler replied to the same day and then sent the correspondence chain to Snr Sgt Stahlhut, Sgt Jenkins and Sgt Curtain marked for their information.

303. On the same day, Snr Sgt Stahlhut sent an email to SC Smart indicating that there had been in interest in Mr Byatt, and he was ‘keen to work in with you in this regard’.287

304. By the time of SC Forte’s death, the SD card in the installed camera had not been accessed, so the images and intelligence captured were unknown to police.

ESC investigation

305. A summary of the Gatton Police Investigation conducted, and complaints made, as well as the issues identified with the response is provided in the report of Det Snr Sgt Scully of the ESC. Following SC Forte’s death, an investigation was conducted by the Ethical Standards Command (ESC) in relation to the Gatton Police Investigation to consider allegations of failing to respond appropriately to calls for service (inadequate investigative response to report of automatic gunfire at Ringwood) and Failure of Duty - Supervisor fail to ensure information relating to automatic gunfire at Ringwood is effectively evaluated and disseminated.288

306. The first interaction with police in relation to these complaints occurred on 17 April 2017, at which time SC Smart had assumed responsibility for conducting an investigation to locate the offender. While a recording of the shots confirmed an automatic weapon was being used, the specific property it was occurring at was yet to be identified.

307. The subsequent internal investigation found that Snr Sgt Browne and SC Smart had assumed they were dealing with a recreational licensed shooter in possession of an illegal weapon. The officers took the investigation at its lowest level and did not give consideration to serious criminal offending. It was noted that ‘despite the protracted offending and high-risk nature, the officers did not consider the investigation outside of operational policing capabilities and did not seek assistance from other QPS specialist units such as the Special Emergency Response Team (SERT).’289 286 Ex E9.42 287 Ex E9.43 288 Ex C28 289 Ex C28, pg. 2 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 44 of 82

308. A number of officers from Gatton Police Station responded to calls for service during April and May 2017. However, no QPRIME occurrences were submitted. Rather, SC Smart and Snr Sgt Browne were briefed verbally or by email. There was no dissemination of information to neighbouring divisions or the Darling Downs District Country Patrol and Support Services Inspector.

309. On the following dates calls were made to report automatic gunfire in the area:290

• January 2017 – resident at Ringwood could hear a very large calibre gun being discharged near the rear of her property.

• 26 February 2017 – resident call to Police Link regarding automatic gunfire east of her address. Not recorded in QPRIME.

• 17 April 2017 – An off-duty police officer made a call-in relation to automatic gunfire near Adare over a 15-minute period. Two further reports made that day by a fellow resident. Neither informant was initially spoken to in relation to report. One of the residents had noted two red shipping containers in the property at the back of her paddock (143 Wallers Road) which she believed the weapons may have been stored in. SC Smart attended and spoke to informant following further report. He did not collect any evidence to support his investigation. No QPRIME report was made.

• 19 April 2017 – An off-duty police officer (previous informant) attended Gatton CIB in relation to the complaints of automatic gunfire in Ringwood. Spoke to SC Smart.

Indicated planned to execute a search warrant when it was established.

• 21 April 2017 – SC Smart swore search warrant for 93 Forestry Road, Ringwood.

Not executed due to staff shortages. Further checks ascertained it was most likely wrong property.

• April 2017 – SC Smart spoke to various residents about the gunfire and location, which included 143 Wallers Road. Further reports of gunfire were heard on 26 April 2017.

• April/May 2017 – During April and May 2017, SC Smart made inquiries with various neighbours about the reports of automatic gunfire.

• 11 May 2017 – Inquiries were made by an informant with SC Smart as she had continued to hear gunfire. Advised that thought it was coming from 169 Wallers Road. Map of Byatt property provided. SC Smart formed the view Adam Byatt was the person responsible for automatic gunfire – he had been convicted of trafficking and had outlaw motorcycle gang links. No notations were made to QPRIME about findings of ongoing investigation – siloed information and investigation.

• 12 May 2017 – Surveillance conducted

• 15 May 2017 – attended 220 Wallers Rd and spoke to the resident, who had not heard gunshots.

290 Ex C28, pg. 5 onwards Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 45 of 82

• 16-17 May 2017 – SC Smart had permission from the resident to enter the property and install a camera. The Cuddeback camera was installed facing the gate of Byatt’s property. No entries were placed on QPRIME or ITAS about the ongoing information, once again siloing the investigation. On 26 May 2017, the camera captured images of Mr Maddison patrolling outside the property with the automatic weapon slung over his shoulder. Images from the camera could only be retrieved by way of the retrieval of the SD card – not live streamed. Risk to officer safety high.291 The Camera was easily detected by Mr Maddison on 26 May 2017 and repositioned for his own use.

• 18 May 2017 – 12:00 pm SC Andre Thaler of the Darling Downs Tactical Crime Group was off duty and parked his private vehicle opposite 220 Wallers Road with the intention of walking up the 4WD only road to walk through the National Park.

Adam Byatt pulled up in a Black Prado. He is said to have aggressively challenged SC Thaler about why he was in the area. Thaler thought the confrontation was suspicious and put in an Intel Report identifying Mr Byatt as the person likely to have confronted him.292 He also telephoned the Darling Downs TCS OIC Snr Sgt Stahlhut who told him to put an intelligence report on QPrime. Given the information as to the Gatton investigation was not on QPRIME TCS were unaware.

• 20 May 2017 – Darling Downs State Intel conducted an evaluation of the intelligence reports by SC Thaler. This failed to identify any links to Mr Byatt and the Wallers property. Tasked to TCS for further inquiries.

• 22 May 2017 – Resident attended Gatton Police Station and reported hearing automatic gunfire over the past 2 months – Wallers and Ford Road. SC Smart advised via email. No QPRIME entry.

• 26 May 2017 – SC Smart attended the vicinity of the Ringwood address to check SD card. However a male in a Hilux made him feel uncomfortable and he left.

310. The ESC investigation found that the officers involved did not ensure information relating to ongoing automatic gunfire was effectively evaluated and disseminated.293 It was found that as the information regarding this investigation was essentially siloed by Gatton Police, there was no means of intelligence collation to allow police to gain better situational awareness, including the ability to possibly apprehend the offender in a timely and safe manner.

311. The Darling Downs District Country Patrol and Support Services Inspector, Inspector Cumming had responsibility for overview of the Gatton Police Division. She confirmed she was not briefed either verbally or in writing about the reports of automatic gunfire in the Ringwood area prior to 29 May 2017.294

312. Ultimately, it was recommended that all of the allegations were able to be resolved through a range of managerial interventions designed to educate, review the incident, and develop improved policing practices.

291 Ex C28, pg. 14 292 Ex C28, pg. 15 293 Ex C28, pg. 2 294 Ex C28, pg. 17 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 46 of 82

313. However, it was noted that the information obtained by Gatton Police as part of their investigation had been siloed, although there was no known information linking Mr Maddison or Mr Byatt to the automatic gunfire.295 Subsequently, several strategies designed to educate and develop best practice policing for police officers from Gatton were instigated to prevent a recurrence and to ensure compliance with QPS policies and expectations.296 These included:297

• Monthly intelligence assessments to inform the Patrol Groups with regard to any intelligence known with respect to firearms, including specific information regarding persons and weapons, and additionally a full review of all shots fired incidents to ensure appropriate attendance, investigation and reporting.298

• The intelligence assessment was developed by the Toowoomba Intelligence Officer from information they collected, which had been entered into QPRIME database system. It included a review of all occurrences involving the word firearm, theft of firearm occurrences, intelligence reports submitted by police officers regarding suspect firearm possession and use, a review of weapons licenses issued where there was a suspected criminal association and shots fired occurrences recorded in the Computer Assisted Dispatch (CAD) reporting system.299 The review considered the appropriateness of the police response and investigation.

• Darling Downs District Firearms Assessment Reports were subsequently used by Patrol Group Inspectors for patrol group meetings and through interactions with OIC to ensure timely investigation and appropriate recording of responses of all firearm information, intelligence and shots fired occurrences.300

• Specific intelligence regarding high-risk persons were managed by the Detective Inspector responsible for the Crime Services Group. In addition, the reports were considered by the District Tasking and Coordination Committee, which included all commissioned officers and intelligence officers.301

• Direction and guidance were subsequently provided by Superintendent Mark Kelly, District Officer of the Darling Downs District to the Patrol Group Inspectors from early 2018 about the use of the Firearms Assessment as a mechanism to review incidents, and how shots fired incidents are to be thoroughly investigated.302 During the course of the implementation period, some matters were re-tasked for further investigation, as the improved practices became part of the norm.

314. Between 2017 and March 2021, over 40 monthly assessments were completed, and continue to provide a greater understanding of the current firearms intelligence for patrol groups in the district and to ensure appropriate policing actions have been undertaken.303 295 Ex A7, pg. 152 296 Ex A7, pg. 159 297 Ex J43 298 Ex J43, [4] 299 Ex J43, [5] 300 Ex J43, [7] 301 Ex J43, [7] 302 Ex J43, [8] 303 Ex J43, [9] Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 47 of 82

315. DSS Buxton noted in his report, with the benefit of hindsight, improved collation, analysis and recording of information may have led to a search warrant being executed at the Wallers Road property before 29 May 2017.304 However, he said it “could not be concluded that this would have prevented Mr Maddison from shooting SC Forte and the following siege situation”. DSS Buxton described the shortcomings of the investigation as an ‘aggravating’ rather than a ‘causational’ factor.

316. DSS Buxton concluded there were “no known links between the property, the Byatt's and Ricky Maddison”. It was likely Mr Maddison would have been identified as residing at the address by police only when they attended the address to execute the warrant.

The assumption is he then would have been arrested on the outstanding matters relating to Ms B.

317. DSS Buxton said that Mr Maddison was aware from 27 May 2017 that Gatton Police had placed a camera to overlook his driveway. He may have used his weapons to try to escape capture if a warrant was executed. Therefore, other police or Mr Maddison may have been shot at, injured or killed. A different siege may have developed from Gatton Police attempting to execute a search warrant.

REVIEW OF THE DECISION TO REINSTITUTE CHARGES AGAINST MADDISON

318. The ESC investigation into Mr Maddison’s death found that the reinstitution of charges from 2015 was a factor that led to the events on 29 May 2017.305 The decision to recommence the charges also formed the legal basis for police to search for Mr Maddison in order to take him into custody, along with the additional breaches of the DVO and offences from 12 March 2017.

319. The decision to reinstitute the charges was considered by the ESC Legal and Policy Unit. A report was subsequently prepared under the hand of Sgt Christopher Elder, which relevantly noted the following:306

• Sgt Lowe’s report to reinstitute the charges was reviewed by each level of his chain of command.

• These reports addressed the sufficiency of the evidence and the public interest in the reinstitution of charges in compliance with the QPS Operational Procedures Manual (OPM) 3.4.3.

• On 24 April 2017, Sgt Tim Hutton, OIC of Toowoomba Police Prosecutions recommended that the 2015 charges be recommenced and concluded there was sufficient public interest to warrant proceeding. Advice was provided that there was no abuse of process.

• Each of the decisions made by the officers complied with current QPS policy and the law in relation to the matter.

• No breaches of discipline or misconduct by QPS in the decision-making process was found during the course of the review.

304 Ex A7, pg. 159 305 Ex A7, pg. 152 306 Ex C17 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 48 of 82

320. DSS Buxton noted that there was credible evidence by which Mr Maddison could have been convicted, with questions of Ms B’s credibility appropriately dealt with by the Court.

I accept that conclusion.

REVIEW OF QPS ORGANISATIONAL RESPONSE – PURSUIT & DEATH OF SC FORTE

321. Consideration was given by the ESC Investigators to compliance with legislation and QPS policy and procedures during the inquiries to locate Mr Maddison on 29 May 2017, the attempted intercept, pursuit and initial response to the shooting incident.307

322. It was noted that following the 13 March 2017 DV incident, police had made a number of attempts to locate Mr Maddison. Strategies included speaking to his associates, surveillance of known addresses, requests for various documents (including bank records) as well as targeted patrols as a result of intelligence provided.

323. The strategy was that if Mr Maddison was located or his whereabouts were known (such as at a future appointment), SERT were to be engaged to apprehend him. If he was unexpectedly located, he was to be immediately arrested by TCS.

324. Following the telephone call to the Darling Downs District Tactical Crime Squad office on 29 May 2017, patrols were deployed immediately to pay phones in the area.

Threat assessment process and applicable OPM

325. In terms of the Threat Assessment and Tactical Decision-making process for police there are no official mandated subject behaviours listed as a benchmark that require police officers to undertake specific actions. For example, there is no requirement that states police must always shoot armed offenders, or handcuff every person they arrest.

326. Instead, the preferred position is to organisationally support officers by providing operationally relevant tools (such as the Situational Use of Force Model 2009, the Threat Assessment and Tactical Decision making process) to assist them in competently, carefully, and continually assessing the circumstances contributing to the situation which will inform their selection of a use of force option, and to reassess these circumstances following initial deployment and prior to the application of any other use of force. While avoiding the artificial creation of a maximum use, the QPS contextualises all use of force options within a paradigm of using the minimum amount force necessary to resolve an incident; and emphasising that the decision to apply force is an individual one for which every officer will be held accountable.

327. Regarding tactical decision making relating to use of force matters, police officers are instructed to utilise the ‘Situational Use of Force Model’ contained in OPM 14.3.2 as a guide. This model assists the police officer to select the most appropriate option(s) to resolve an incident. The Situational Use of Force Model is not restrictive. Police officers may select other 'use of force' options to escalate or de-escalate the 'use of force', as necessary.

307 Ex A5, pg. 644 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 49 of 82

328. Officers are instructed that it is good policing practice to perform a continual threat assessment about the level of risk, both real and potential. Good threat assessment means accurately weighing up any person, object, or place which could put the officer (or others) at risk, and understanding that in all conflict situations, every person, object, or place fall into one of two (2) categories.

I. Category 1 – HIGH RISK. High risk refers to an obvious risk e.g., attending an armed robbery call, attempting to arrest a subject armed with a weapon, attending a ‘shots fired’ job, etc. OR II. Category 2 – UNKNOWN RISK. Unknown risk refers to an undisclosed risk e.g., every person, object or place which is NOT a High Risk.

329. Police Officers are instructed that they should never use the term “Low Risk”, as this may create a complacent attitude. Threat assessment requires continuous re-evaluation and being mindful that threat levels rise and fall during use-of-force incidents. Police officers must continuously reassess the situation and take appropriate safeguards. The by-product of the continuous threat assessment process is the creation of situational awareness.

330. As with all use of force options, the decision must be judged according to the circumstances characterising the incident at the specific time, and may be influenced by risks, both actual, or potential.

331. The policy relating to the QPS use of force matters is contained within the Operational Procedures Manual. The aim of the manual is to provide guidance and instructions in all aspects of operational policing. To this end, members are to comply with the contents of the manual so that their duties are discharged lawfully, ethically, and efficiently.

332. The provisions of the OPM - Chapter 14 Operational Skills and Practices, 14.3.2.

Situational Use of Force Model – 2009, specifies the five (5) conditions that must be satisfied for an application of force to be regarded as appropriate, and in accordance with the Service’s official organisational position as it relates to the lawful application of force. All ‘use of force’ applications must be:

(a) authorised;

(b) justified;

(c) reasonable / proportionate / appropriate;

(d) legally defensible; and

(e) tactically sound and effective.

Threat assessment process followed with respect to Mr Maddison Knowledge prior to pursuit

333. In terms of the threat assessment process of police officers conducting searches for Mr Maddison, it was noted that:308

• Mr Maddison was classified as a Category 1 – High Risk offender given the QPRIME flags created following 13 March 2017 incident, which included the possession of a firearm which he had fired during the incident.

308 Ex A5, pg. 662 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 50 of 82

• Mr Maddison was cited in several of the Toowoomba Patrol Group (TPG) Priority Patrol Taskings in 2017 following the March 2017 incident.309Each stated that he was wanted for questioning and it was flagged that he had used a firearm. The inclusion of the Arrest Warrant was noted after April 2017.

• Toowoomba Station had a muster at the commencement of each shift and the TPG priority patrol taskings and District wanted persons were discussed.310

• The BOLO Officer Safety Alerts also provided information about the circumstances surrounding Mr Maddison’s offences and risk to officer safety.

334. Officers from the TCS, including SC Forte and SC Nielsen, had been involved in efforts to locate Mr Maddison and would have been aware of this information. SC Nielsen had previously spoken to Mr Maddison on the telephone 24 May 2017. Given the relationship between SC Forte and Mrs Forte it was considered by the ESC investigator that it was likely he was aware of more information about Mr Maddison than was recorded in official documentation.311

335. According to SC Nielsen, there was no discussion in the vehicle during the course of the pursuit about what the plan was or with respect to Mr Maddison. Knowing that Mr Maddison was a ‘high-risk’ offender, she had assumed that they would arrest Mr Maddison and there may be some hands-on use of force.312

336. SC Hill confirmed that prior to the pursuit he had been made aware Mr Maddison was ‘dangerous’, had a firearm and that he was wanted on four arrest warrants.313 Constable Poulton had similar knowledge of Mr Maddison.314 Pursuit of Mr Maddison

337. Once Mr Maddison was located at the pay phone, an intercept was attempted by TW208 by activation of lights and sirens. A pursuit was then commenced.

338. The QPS Policy with respect to pursuits at the time of the incident was detailed in the QPS Traffic Manual, Chapter 10. On 29 March 2018, the policy was updated and moved to OPM Chapter 15.315

339. The radio transmissions relating to the request and authorisation of the pursuit by Comco (and pursuit controller), Sgt Douglas are detailed in a table.316 Of note at 1:56:11 Comco states: Yeah roger. Pursuit authorised for the time being. Comco is 4008044. You must continue to relay the speed, the road conditions. At any time it appears dangerous at all you must advise and we will reassess.’ 309 Ex A5, pg. 663 onwards 310 Ex A5, pg. 666 311 Ex A5, pg. 668 312 Ex A5, pg. 671 313 Ex A5, pg. 673 314 Ex A5, pg. 674 315 Ex A5, pg. 688 316 Ex A5, pg. 688 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 51 of 82

340. Sgt Douglas relevantly stated the following during the inquest:

• He had been a Comco for three years prior to the incident.317

• He described pursuits as requiring an ‘imminent need’ with an ‘urgency to continue’, further stating that he did not like pursuits generally due to the inherent danger.318

• He had not heard of Ricky Maddison prior to 29 May 2017.319

• He acknowledged that the decision to authorise the pursuit and continue the pursuit essentially involved two different decisions, with the initial decision related to an imminent need to apprehend the offender, which remained with respect to the secondary decision as whether the pursuit should be abandoned, as well as a host of other considerations, such as the manner of driving and the risk to the public.320

• A District Duty Officer, who could have overseen and taken command of the incident, would have been of great assistance.321

341. In accordance with the Pursuit Policy, the pursuit commenced when the marked police vehicle activated the lights and sirens while positioned behind Mr Maddison and he failed to stop. Pursuant to s.10.5.2 of the Policy the pursuit was justified, and based on a reasonable belief that Mr Maddison had committed an indictable offence. It was therefore a pursuable matter.322

342. During the course of the pursuit, updates were provided by the various vehicles, including TW753, to the Comco in accordance with the procedure (s.10.5.3 Notification of Pursuits).

343. Point 10.5.4 of the Policy in conducting pursuits, requires that all officers, not just the Pursuit Controller conduct continuous risk assessments. It states: 10.5.4 Conduct of a pursuit

POLICY Officers who have commenced or are involved in a pursuit, are to be aware that safety of all members of the public, police officers and suspect persons is the primary consideration.

Officers should embrace the ‘Consider all Options and Practise Safety’ (COPS) philosophy when dealing with vehicle interceptions that transition to pursuits and conduct a continual risk assessment in accordance with s. 10.5.5: ‘Risk assessment’ of this chapter.

10.5.4 Risk assessment

POLICY Prior to making a decision to commence a pursuit, or to continue a pursuit, officers are to conduct a risk assessment of all factors impacting or potentially impacting on the conduct of the pursuit.

317 T7-55 318 T7-56 319 T7-56 320 T7-86-91 321 T4-26; 322 Ex A5, pg. 690 - 692 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 52 of 82

Officers need to be mindful that the risks associated with a pursuit are dynamic and will change in a very short timeframe and consequently the risk assessment is to be continual.

Officers are to consider that death or serious injury to any person may be a consequence of conducting a pursuit. Where the pursuit would expose the police, public or the occupants of the pursued vehicle to unjustifiable risk, it should not be commenced or if commenced, should be abandoned in accordance s. 10.5.10: ‘Abandoning a pursuit’ of this chapter.

344. Stingers were deployed during the pursuit while Mr Maddison was driving along the Warrego Highway.323 Further deployment had been planned.324 The relevant OPM with respect to tyre deflation devices is s.10.7.1. Comco, Sgt Douglas had called for the stingers within minutes of the pursuit commencing and stated that he did so as he needed to bring it to a conclusion ‘as safe as possible’.325

345. Section 10.5.10 of the policy as was in place at the time relates to abandoning a pursuit and stated that: A pursuit must be abandoned immediately it creates an unjustifiable risk to the safety of any person. The risk factors outlined in s. 10.5.5: ‘Risk assessment’ of this chapter are to be continually assessed by all officers involved in a pursuit and are to be considered when deciding whether to abandon the pursuit.

POLICY Officers are to abandon a pursuit when:

(i) the pursuit exposes the police, public or the occupants of the pursued vehicle to unjustifiable risk of death or serious injury; (ii) continuing the pursuit is futile; (iii) visual contact with the pursued vehicle has been lost and is unlikely to be regained; (iv) the identity of the driver of the pursued vehicle is known and it is not necessary to immediately apprehend the person; (iv) the driver of the pursued vehicle is a child, unless the reason for the pursuit and the circumstances are so serious it is necessary that the child be immediately detained; (vi) directed by the pursuit controller that:

(a) a Polair Queensland helicopter is in the vicinity of the pursuit and has commenced electronic surveillance of the pursued vehicle; and

(b) the ground-based pursuit is to be abandoned.

346. After Mr Maddison left the Warrego Highway and turned onto Forestry Road before Wallers Road, there were no radio transmissions to the Pursuit Controller expressing concern about his manner of driving or any new risk factors.326 The only transmissions related to the Wallers Road being an unsealed road, namely:327 323 Ex A5, pg. 708 & 709 324 Ex A5, pg. 709 325 Ex A5, pg. 713 326 Ex A5, pg. 721 327 Ex A5, pg. 721 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 53 of 82

• 14.15.22 hours when TW270 indicated “I believe that this particular road is a dead end if it’s followed to the end.”

• 14.16.01 hours when TW269 stated “Wallers Road goes up to Logan’s Road up the top of Seventeen Mile Road at Helidon if we can get a vehicle at Seventeen Mile Road. That’s where it comes out. It’s a 4WD track and I don’t think any of our vehicles will get up there.”

• 14.16.52 hours TW269 stated “You might want to also organise a unit for Sandy Creek Road in Grantham. This can make its way back on to Fords Road which leads to Sandy Creek Road back into Helidon also.”

347. Dashcam footage shows Mr Maddison turn into Wallers Road at 2:15:47 pm. While travelling on Wallers Road, the Helidon crew made a series of broadcasts requesting that vehicles attend the likely exit points.

348. At 2:17:14 pm, Wallers Road appears to have more trees visible on the side and information is asked from TW753 (SC Forte and SC Nielsen) about the status of POLAIR. At this time, TW753 is traveling at a speed of 70km/hr. The terrain changes on the roadway at 2:17:50 pm and more ruts are visible. The speed of TW753 had dropped to 40klm/hr.328 Dust frequently obscures the view of the Mr Maddison’s vehicle.

349. Ultimately, Det Snr Sgt Hinshelwood concluded that:329 The decision to commence and continue to pursue Mr Maddison’s vehicle was sound and in compliance with QPS Policy. During the pursuit strategies to resolve the pursuit were actioned. This included the deployment of, and planned deployment of type deflation devices (stingers), requests for Polair and advice to the neighbouring Communications Centre of the pursuit.

The risk assessment of the officers involved was consistent with QPS Policy. It is noted when Wallers Road became less open the TCS crew asked Communications for a status of Polair, indicating their consideration of alternatives to continuing the pursuit.

The change in terrain on Wallers Road occurred over a small distance. In her interview Acting Sgt Nielsen indicated, ‘When we turned down the road ah just before it happened, minutes before it, seconds really, Brett said to me it’s like he’s leading us somewhere and I said I just thought the exact same thing’.

It is considered the officers were in the process of assessing the situation and risk, and considering the alternatives to pursuit however Mr Maddison stopped the vehicle and fired upon them before they had the opportunity to action any decision they made as a result of that risk assessment.

As stated previously, although a number of instances were identified where the QPS response to the incident was suboptimal, none of these instances impacted on the survivability of Brett Forte.

The identification of deficiencies can however, be considered as an opportunity for organisational learning and/or process improvement, and therefore are suitable for referral to the respective units within the QPS for consideration.

328 Ex A5, pg. 722 329 Ex A5, pg. 790 & 791 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 54 of 82

Critical Incident Review by Inspector Timothy Mowle

350. In February 2021, Inspector Timothy Mowle, who managed the operational review portfolio, Ethical Standards Command, was asked to consider and review the tactics employed by QPS officers in the lead up to the confrontation with Mr Maddison on 29 May 2017, which resulted in SC Forte’s death.330 He was briefed with a range of material, including video footage and documents relating to the incident.

351. In order to conduct an incident analysis, Inspector Mowle divided the incident into three phases, and considered the response by QPS accordingly.331 The scope of the analysis was limited to the appropriateness of the following matters:332

(a) Other tactical arrest options, as an alternative to engaging in the pursuit; and

(b) The tactics employed during the pursuit.

352. The Phases were defined as follows: I. Pre-Incident Phase: This phase was defined as all police activities conducted prior to the phone conversation with Sgt Jenkins on 29 May 2017.333 II. Incident Phase: This phase was defined as the time of the phone call with Sgt Jenkins until the critical action against Mr Maddison.

III. Post-incident Phase: This phase was defined as the period following the critical action against Mr Maddison, including the post-incident investigative process.

353. Based on the information provided, Inspector Mowle was of the view that all activities in relation to the apprehension of Mr Maddison were ‘high risk’, as indicated by Det Snr Sgt Hinshelwood, and met the definition of a ‘high risk situation’ in the OPM.334

354. Inspector Mowle noted that Mr Maddison had a previous history of violence. The domestic violence offences he recently committed were serious and involved a firearm.335 In addition, he found that the high risk nature of Mr Maddison’s conduct when taking action against him was considered, documented and had been disseminated.336 330 Ex J39 331 Ex J39, [15] 332 Ex J39, [17] 333 Ex J39, [15] 334 Ex J39, [25] 335 Ex J39, [26] 336 Ex J39, [27] Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 55 of 82

355. This meant that any encounter with Mr Maddison would likely result in a tactically dangerous situation as defined in the OPM.337 In those circumstances, officers are required to consider a number of issues including safety.338 Officers are to conduct risk assessments regarding any threat from any person, object or place and categorise the risk as high or unknown. The Situational Use of Force Model is to be considered and an appropriate option chosen.

356. Tactical issues also need to be considered, including the need to establish inner and outer cordons and whether SERT needed to be notified.

357. Inspector Mowle found a lack of evidence of a planned approach to the apprehension of Mr Maddison.339 However, he acknowledged there was a degree of planning for Mr Maddison’s apprehension, noting an email sent by Sgt Curtain to Inspector Isherwood and Sgt Stahlhut on 24 May 2017: Intended Tactical Action will include:

358. If any reliable/verified sighting or information relating to the whereabouts of MADDISON is obtained, SERT will be notified in all instances.

359. If we get extremely lucky and stumble on top of him inadvertently at a campsite or track MADDISON will be arrested by TCS.340

360. Inspector Mowle considered the threat assessment and potential for any police action against Mr Maddison resulting in a tactically dangerous situation, the following planned approach in line with the policy would have been appropriate:341

• Prior to attending an incident, officers should have an approach that allows for the minimum use of force necessary to be applied, in order to resolve the incident.

• Continual threat assessments need to be conducted, and reassessed, in order to make sound decisions about the management of an incident and appropriate situational use of force.

• An Incident Action Plan may be developed applying the elements of ICENRIRE

• Isolation, Containment, Evacuation and Negotiation and Resolution.

359. In relation to the threat assessments to be conducted, there are various QPS policies that can apply and provide guidance to officers, including continual threat assessments and risk assessments during the course of pursuits (which applies prior to and during a pursuit).342 Where the pursuit would expose the police, public or the occupants of the pursued vehicle to an unjustifiable risk of death or serious injury, the pursuit should not be commenced or is to be abandoned 337 Ex J39, [28] 338 Ex J39, [28] 339 Ex J39, [29] 340 Ex D102 341 Ex J39, [29] 342 Ex J39, [31] Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 56 of 82

360. Having considered the data provided, Inspector Mowle noted there had been threat assessments undertaken and documented, such as the Officer Safety Alerts and Patrol Group Priority Taskings. Similarly, risk assessments were also undertaken during the course of the pursuit, with police units relaying information about Mr Maddison’s manner of driving, weather, environmental factors, and traffic conditions to the pursuit controller.343 Inspector Mowle concluded the contents of the numerous policies were sufficient in offering guidance to officers involved in this incident.

361. Inspector Mowle concurred with the comments of Snr Sgt Damien Hayden in relation to tactical decision making. He noted options for arrest can be divided into either operational arrests or tactical arrests. The primary difference between a tactical arrest and an operational arrest is that standard officer skills training provides a base level of knowledge and skills sufficient for officers to perform an operational arrest. A tactical arrest requires more planning, better skills, knowledge and equipment to ensure the intended outcome is achieved effectively and safely.

362. While there were options to effect a tactical arrest for Mr Maddison, none were available as his whereabouts remained unknown despite extensive attempts made to locate him.344

363. Inspector Mowle noted there may have been a missed opportunity during the phone conversation with Sgt Jenkins to locate Mr Maddison by setting up a meeting at a location other than the Toowoomba Police Station. Covert surveillance officers might then have been deployed to establish where he was residing and SERT could have been engaged for the purpose of a planned apprehension.345 Similar missed opportunities may have presented after Mr Maddison had called the police station on several occasions, providing scope to plan for the next occasion that he called.

364. Inspector Mowle agreed with DSS Hinshelwood’s assessment that the pursuit was conducted in compliance with QPS policy.346 He noted that it is broadly accepted that pursuits are inherently dangerous and pose a significant risk to pursuing officers, occupants of the vehicle being pursued and the public. The safeguards stipulated in the policy, in Inspector Mowle’s view, such as a dedicated pursuit controller, ongoing risk assessments and restrictive use of force options all were enlivened and appropriate during the pursuit of Mr Maddison.347

365. However, Inspector Mowle considered there was a missed opportunity for an officer with knowledge of Mr Maddison’s background, the police actions to date and the ability to formulate and communicate an effective plan in line with previously determined threat assessments, to take overall tactical command during the pursuit.348

366. Inspector Mowle noted there was a lack of evidence to suggest a tactical plan had been developed or communicated to all police involved for the purpose of effecting a tactical resolution. He emphasised the following:349

• Aside from the pursuit controller, there was no evidence of overall tactical command.

343 Ex J39, [32] 344 Ex J39, [] 345 Ex J39, [38] 346 Ex J39, [39] 347 Ex J39, [39] 348 Ex J39, [40] 349 Ex J39, [41] Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 57 of 82

• There was no commander’s intent communicated, such as immobilize the vehicle with stingers and then establish a cordon to isolate until SERT arrive.

• There was no tactical plan communicated via police radio to or from any officer involved.

• There was no suggestion of 'actions on' or contingencies in the event of a confrontation, attempt to elude police, injuries, accident, or breakdown.

• There was no mention of resource requirements commensurate to the threat assessment, such as ballistic vests or a patrol rifle. Those were only mentioned after SC Forte was shot.

• There was a general lack of vital information being transmitted to other units that could have assisted with situational awareness.

367. Inspector Mowle considered that these issues could have been alleviated by the presence of dedicated on-ground supervisors, which were only implemented following this incident.350

368. In terms of the overall strategy and resolution being considered during the pursuit, it appeared to Inspector Mowle that the mobilisation of Polair and SERT were the two primary options being considered. In his view, given the circumstances considered in their totality these options would have been authorised, justified, reasonable, proportionate, appropriate, legally defensible, and tactically sound and effective.351

369. The third option being considered included immobilising the vehicle driven by Mr Maddison. The option to immobilise the vehicle then isolate and contain him in the vehicle, and either negotiate or await the arrival of SERT, would be considered a sound tactic for a number of reasons. Compared to the POI being contained in a stronghold, a POI contained within a vehicle is limited in their movement, police can maintain direct observation at all times, and generally have direct and immediate access to the POI.

370. Ultimately, Inspector Mowle reached the following conclusions:352

• The content of the numerous QPS policies, which were relevant to the incident were sufficient in offering guidance to the officers.

• Alternative tactical arrest options were not viable at any time prior to police commencing the pursuit, due to Mr Maddison’s whereabouts being unknown.

• Police had conducted extensive enquiries in an attempt to locate Mr Maddison.

• There were missed opportunities to develop a strategy in the event that Mr Maddison telephoned the police station again.

• Officers involved in the pursuit of Mr Maddison operated within the QPS policy provisions.

350 Ex J39, [42] 351 Ex J39, [43] 352 Ex J39, [45] Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 58 of 82

• Officers engaged in the pursuit of Mr Maddison for the purpose of isolating and containing Mr Maddison at a location, until the arrival of SERT.

• There was a missed opportunity to broadcast a tactical plan, via the police radio, to all units during the pursuit.

• Given the nature and spontaneity of the confrontation between Mr Maddison and TW753 at Wallers Rd, greater tactical command during the pursuit would not have prevented the confrontation from occurring.

• There was an absence of on-ground supervision during the pursuit, which has been adequately addressed through the introduction of on-ground supervisors.

371. When asked at the inquest about the decision to follow Mr Maddison down Wallers Road during the pursuit, Inspector Mowle acknowledged that with his previous experience, particularly as a SERT operative, he may have potentially made a different tactical decision.353

372. Inspector Mowle described the confrontation that occurred on Wallers Road as inevitable. However, he noted that had there been an on-ground supervisor who provided more clarity around tactics, the outcome may have been different and there may have been the ability to isolate and contain Mr Maddison.354 Mr Maddison’s death - Statement of Senior Sgt Hayden

373. Following the deaths of SC Forte and Mr Maddison deaths, a statement was sought from Snr Sgt Hayden.355 Officer Hayden was formerly the OIC for Operational Skills and Tactics Program at the Queensland Police Academy. He has provided professional opinions regarding the Police Use-of-Force issues and police training with respect to various matters.

374. Snr Sgt Hayden was called to the scene shortly after Mr Maddison was shot to provide expert assistance.356 He was given a walkthrough of the scene and subsequently received the following material:357

• A video timeline file, including dashcam footage from SC Forte’s vehicle;

• A video file containing imaginary of the Stronghold by POLAIR;

• Records of Interview conducted with SERT operators; and

• Audio files of records of interviews with SERT operators.

375. Snr Sgt Hayden formed the view that Mr Maddison’s ongoing course of conduct and weaponry posed a continuous and extremely high threat to the police response.

Specifically, he noted the following:

• Mr Maddison was agitated and argumentative during his call with Sgt Jenkins.

353 T9-59 & 60 354 T9-61 355 Ex B51 356 Ex B51, [29] 357 Ex B51, [39] Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 59 of 82

• He led officers on a low-speed pursuit. He considered this was a deliberate tactic to force a violent confrontation with police.

• He had an automatic weapon in his vehicle, which he used to shoot at the cabin of SC Forte’s vehicle.

• In the stronghold, Mr Maddison fired deliberately at police and POLAIR.

• He was offered a surrender plan to ensure he entered custody safely.

• He used two rifles during the siege.

• He displayed a willingness to fire indiscriminately without regard.

376. The evidence supports that SERT operators were performing functions of the Police Service at the time they discharged their firearms acting in the execution of their duties.

SERT Operators 177 and 175 fired at Mr Maddison due to the threat posed.358 Mr Maddison was killed as a result of shots fired by SERT Operator 177 in the execution of his duty.

377. Officer Hayden was of the view that SERT operator 177 and 175 were justified in their decision to use lethal force against Mr Maddison given the threat he posed.359 The level of force applied was not excessive or gratuitous and was ‘reasonably necessary’. I accept those conclusions.

QPS Incident Command Review 360

378. A formal review was conducted in relation to the QPS Incident Command System (QPSICS) methodology as it applied following the shooting of SC Forte.361 A report was prepared detailing the findings of the Incident Command Training Section (ICTS), People Capability Command.

379. The QPS-ICS is utilised to flexibly resolve and adapt to emergent situations of any nature, and contains two important aspects. The first is unity of command, that theorises that a subordinate will report to one controller. The second is that each entity is contributing to predetermined strategy formulated and agreed upon to resolve the incident.362 It is not a structure but rather a command, control and coordination model.

380. Incident command operations are intended to be proactive with the thoughts and actions of the PFC being purpose driven and not simply reactive.363 The PFC is responsible for the implementation of the QPS-ICS. In all operational incidents, the PFC is required to gain an immediate understanding of the environment to successfully resolve any incident utilising a sound and timely decision-making process.364Upon the Commander gaining situational awareness the Police Forward Command Post is established. This is the platform to develop an Incident Action Plan to incorporate strategies and contingencies.365 358 Ex A7, pg. 112 359 Ex A7, pg. 114 360 Ex F1.1 361 Ex F1.1, pg. 1 362 Ex F1.1, pg. 6 363 Ex F1.1, pg. 7 364 Ex F1.1, pg. 8 365 Ex F1.1, pg. 9 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 60 of 82

381. The PFC requires an understanding of the three cognitive levels attributed to situational awareness, namely:366 i. Perceiving the incident involves gaining an understanding of the current status, key incident characteristics and overall dynamic of the scene through an initial assessment; ii. Comprehension – extends knowledge learned from initial assessment with significance attributed to the environmental factors; and iii. Projection – final stage of situational awareness and the most valuable. This is the ability to perceive what is likely to occur within the environment in the near future.

This stage enables the PFC to recognise a suitable opportunity to incorporate a particular strategy.

382. Having regard to this methodology, the following was noted with respect to this incident:367

• Sgt Thomas in TW269 was the most senior officer present at the incident, prior to the appointment of a police forward commander. Responsibility for incident management (command) rested with him. However, upon receiving gunfire from Mr Maddison, TW269 advised, “we are getting out of here”. The effect of this transmission by TW269 was a significant reduction of effective frontline leadership and reduced the other officers’ ability to recover the occupants of TW753.

• Sgt Browne was appointed as the initial PFC by police communications at 2:36 pm.

• At 2:38 pm, Inspector Cumming indicated she was five minutes from the incident location and requested details about PFCP.

• At 2:38 pm, Snr Sgt Browne advised the location of PCFP – 500 m east of Wallers Road. This was considered to be dynamic, and expedient given the situation.

• Snr Sgt Browne did not formally announce his command or transmit a commander’s intent as best practice would mandate.

• Snr Sgt Browne formulated a rapid plan to extract SC Forte from the vehicle.

• Staff were positioned on Wallers Road and no cordons were established.

• The inability to obtain complete situational awareness, aligned with a confirmed location of Mr Maddison, ensured confusion prevailed among the police contingent and was demonstrated in the lack of information flow to the QAS.

• At 2:52 pm Inspector Cumming arrived at Forestry Road which she believed was the PFCP.

• At 2:56 pm Inspector Cumming announced command. However, there was no mission or intent communicated. She did not seek specific information at the time 366 Ex F1.1, pg. 9 367 Ex F1.1, pg. 12 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 61 of 82

to enhance her situational awareness. Safety was paramount and she could be heard telling staff to wear vests.

• There is no evidence that Inspector Cumming obtained full situational awareness as she did not transition between the three cognitive levels of situational awareness required to establish full comprehension. This was due to her not seeking specific information from her available resources and her immersion in recovery efforts at the extraction point.368

• There was poor information flow about the exact location of PFCP by Inspector Cumming. A SITREP was not sought and she focused on extraction of SC Forte.

• Inspector Cumming did not initially liaise with SERT.

• There was no handover of the inner cordon by Inspector Cumming to the SERT Tactical Commander.

383. Overall, it was noted that Command activities were impeded by a lack of situational awareness at the outset.369 The failure to obtain SITREPS hindered the ability to create effective plans for the response to the incident. Sgt Douglas, the COMCO, indicated that he had difficulty finding the location of the pursuit and the TCS vehicle on the map utilised in Atlas. This had a negative effect on his situational awareness.

384. The following further shortcomings were identified:370

• Queries about accessing the best route to the incident location were unable to be answered. A quick and safe route to the incident had not been established and communicated to the units attending. No information was provided to responding crews about the specific location they should attend. For example, the PFCP or rendezvous point, which inhibited the effective delegation of tasks.371

• A meeting point was not established for police crews or other emergency crews responding to the incident.

• No formal request was made for SITREPS from officers at the scene or by communications.372

• Radio communications did not use opportunities to ascertain information about the TCS vehicle or those located nearby to gain situational awareness.

• While traveling to the scene conflicting information was being transmitted by crews in attendance. This had a direct impact on Inspector Cumming’s ability to gather situational awareness and obtain the key elements. She did not initiate Distal Command and did not co-ordinate staff or resources while travelling to the scene.

• Incorrect information was provided to crews in the danger zone.373 368 Ex F1.1, pg. 13 369 Ex A5, pg. 735 370 Ex A5, pg. 738 onwards 371 Ex A5, pg. 840 372 Ex A5, pg. 840 373 Ex A5, pg. 841 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 62 of 82

• Staff entering the Communications Room was distracting. This issue was identified by Sgt Douglas and Inspector Angus.

• The extraction of SC Forte was delayed. However, this was considered appropriate in the circumstances due to conflicting reports of Mr Maddison’s whereabouts and the location of TCS vehicle.374

• While Inspector Cumming and Snr Sgt Browne ensured the safety of staff under their control, there was no indication there was a formal handover. Inspector Cumming also incorrectly allowed Snr Sgt Browne to continue to coordinate activities at the PFCP.375

385. A series of recommendations were made as a result of the shortcomings identified in the review of the incident:376

• Ongoing training is required across all QPS rank structure for incident command training, including compulsory online learning products in relation to methodology of incident command and workshops.

• Immediate commencement of Incident Management Team Training.

• Enhanced Legal Studies in Policing 3 training to expanded virtual reality scenarios validated by practical competency-based field exercise.

• DDO/Shift Supervisor Incident Command Training package and refresher.

• Regional workshops and train the trainer courses.

• Command Refresher Course aimed upon the rank of Inspector or above.

• Incident Command Training aimed at the rank of Sergeant devolved to Constable.

386. During the inquest, Snr Sgt Alexander McBroom was called to speak to the review and conclusions reached.377 He reiterated the need for incident command training to be directed towards Sergeant and Senior Constable level officers in a more widespread manner than is currently offered.378 This training needs to encompass incident command team training for all members of a team responding to a critical incident of this nature, as well as refresher training for Inspectors to ensure skills taught in this regard are maintained.379

387. Snr Sgt Christopher O’Shea provided a statement detailing the response to and implementation of the ICTS recommendations, which can be summarised as follows:380

• All QPS Regions and Commands regularly test their response capability through discussion and field exercises, which are supported by the State-wide Security and Counter Terrorism Network and the Disaster Management Support Officers 374 Ex F1.1 375 Ex F1.1 376 Ex F1.1 377 T8-33 onwards

378 T8-43 379 T8-43 & 44 380 Ex J38 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 63 of 82

network. Such activities are followed by evaluation and feedback, which are designed to build leadership and command skills across a broad range of areas.381

• Since the provision of the review, there has been a paradigm shift in the QPS approach to leadership training, with an independent review commissioned of leadership development in late December 2019. The result of this review was the development of the Leadership Capability Program Project, which commenced in July 2020. The objectives and learning outcomes of the LCP have been mapped to the Public Service Commission, Leadership Competencies for Queensland.

This mapping clearly demonstrates an increase in leadership capability and the curriculum design encourages the learners to strive for the next level of leadership.

The LCP will be a compulsory pathway for promotion for QPS sworn staff from July 2021. With respect to incident command the program will work at each level, commencing at Senior Constable, targeting an officer’s leadership, command, control and coordination skills.382 The LCP program also requires officers who complete the requisite multi-modal distance education components to attend a job ready workshop, which covers the essentials of command in an immersive environment.

• The Command and Immersive Learning team has implemented the ‘Regional Incident Command Workshop – Train the Trainer’ Renewal Program, which ensures each region has a strong local cohort of QPS ICS Subject Matter Experts who can deliver two-day Incident Command for Supervisors Workshops, which utilizes Virtual Reality kits, allowing student to practice their skills in real time siege like scenarios.383 Evacuation of SC Forte

388. Snr Sgt Hinshelwood’s report noted that police officers responding to tactically dangerous situations employ the Incident Command System (ICS) principles to assist the planning and execution of activities in seeing an incident through to completion.384

389. This involves responding and developing incident action plans to achieve the objectives of the initial tactical response. The ICS functions of Command, Operations, Planning, Intelligence and Administration and Logistics (COPIA) work in an integrated way to deliver the mission objective for the incident.

390. Initially, a Police Forward Commander (PFC) may perform all the ICS roles until sufficient staff are available to delegate other roles (aside from Command). The cells which carry out these functions are physically located within the Police Forward Command Post (PFCP). They assist the PFC by developing specific incident action plans to address aspects of an incident, such as a traffic management plan, foot and vehicle escape plans, surrender plans, which are necessary to resolve the incident.385 381 Ex J38, [4] 382 Ex J38, [5] 383 Ex J38, [6] 384 Ex A7, pg. 17 385 Ex A7, pg. 17 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 64 of 82

391. As noted above the initial PFC in relation to this incident was Snr Sgt Browne, OIC of Gatton Police. He attended Wallers Road shortly after SC Nielsen made the call at 2:18 pm that shots had been fired by Mr Maddison.386 Snr Sgt Browne’s priority became coordinating the extraction of SC Forte as well as the isolation and containment of Mr Maddison.

392. At 2:30 pm, after SC Forte was extracted from the vehicle and found to have been shot, Snr Sgt Browne, SC Thomas and SC Ritchie attempted a rescue. However, they were forced to abandon due to the sound of automatic gunfire. It was decided to cordon and contain, forming a PFC post at 169 Wallers Road to enable better coordination of responses.

393. At 2:36 pm, Inspector Angus of the Police Communications Centre at Toowoomba declared Snr Sgt Browne as on-scene PFC, making other units aware that he was in proximal command.

394. At 2:40 pm, Constable Poulton drove SC Forte in a police vehicle along Wallers Road towards the QAS staging area. Automatic gunfire could be heard from time to time, with police unaware of Mr Maddison’s whereabouts.387

395. At 2:46 pm, Snr Sgt Browne advised that the inner cordon would tactically reposition to 169 Wallers Road until SERT arrived with more resources to allow the inner cordon to be adjusted. Snr Sgt Browne acknowledged that he did not have sufficient resources or intelligence to place better-defined cordons.

396. At 2:47 pm, Constable Poulton stopped the police vehicle outside 50 Forestry Road.

Officers Poulton and Thomas removed SC Forte and placed him on the ground before continuing CPR. The QAS arrived at 2:52 pm and took over more advanced medical care.388

397. Jamieson Woods, QAS Officer in Charge of the Gatton Station, attended the scene to render assistance to SC Forte.389 He was with paramedics, Maria Mourilyan and Jane Ong. Gunfire was heard while assistance was being provided to SC Forte. It was noted by Ms Mourilyan that SC Forte was in traumatic arrest with a GCS of 3. He required continued CPR, which was already being administered at the time of their arrival.390

398. Interviews with various officers at the scene indicated that prior to QAS arrival attempts were made to conduct CPR. However, it appears SC Forte may have already been deceased.391 It is clear that it was also difficult to access SC Forte who had been placed in the back of the vehicle in an attempt to remove him from the scene as quickly as possible.

399. At 2:48 pm, POLAIR advised that they were at the incident location and scanning. SERT arrived in the area of operation as well and were liaising with POLAIR. At 3:04 pm, SERT Commander Inspector Partrige arrived at the PFCP.392 386 Ex A7, pg. 17 387 Ex A7, pg. 18 388 Ex A7, pg. 18 389 Ex A5, pg. 122 390 Ex A5, pg. 125 391 Ex A5, pg. 115 onwards 392 Ex A7, pg. 18 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 65 of 82

400. At 3:10 pm, Snr Sgt Browne confirmed that POLAIR had visual containment and would be able to advise if Mr Maddison left the stronghold. There was nothing stopping Mr Maddison leaving the stronghold as officers were only placed at obvious points of egress from the area. This was the first sighting of Mr Maddison after SC Forte was shot and allowed for a far greater situational awareness for the officers responding.

401. The time from Mr Maddison firing shots at SC Forte until he was removed from the vehicle was approximately 12 minutes. This was due to the position of the vehicle and the high-risk environment. Once SC Forte was removed from the vehicle officers provided basic first aid treatment with CPR being commenced a short time later. It was around 31 minutes before CPR was commenced and 34 minutes before the QAS arrived.

402. Given the nature of SC Forte’s injuries, Investigators concluded it was likely he was deceased before being removed from the vehicle.393 Recommendations made by Det Snr Sgt Hinshelwood

403. Since late 2017, communication between the QPS Communications and QAS has been enhanced by the introduction of the Inter-Agency Computer Aided Dispatch Electronic Monitoring System (ICEMS).394

404. Det Snr Sgt Hinshelwood recommended that SITREPS be included in the OST curriculum, particularly in armed offender scenarios.395 She noted that this incident demonstrated how the absence of SITREPS leads to diminished situational awareness for communications, incident commanders and other police attending.

405. Support was also provided for the implementation of further District Operations Centres, as have been put in place on the Gold Coast. This permits a static command, control, communication and intelligence node to coordinate the District’s resources and activities.396 Toowoomba PCC was at or beyond capacity responding to this incident and such centres would allow for the centralisation of command.

406. With respect to training, it was noted that Communications personnel, District Duty Officers and Incident Command Training is currently siloed with different sections creating the training curriculum. Officer Hinshelwood considered that this incident demonstrated a need for a consolidated approach to training and exercising, particularly with respect to active armed offender incidents.397 A coordinated approach to training may assist to enable officers to have a better understanding of each other roles and requirements to ensure an effective use of resources.

407. In response to the shortcomings identified about command of the incident, Inspector Cumming acknowledged that while she accepted some of the criticisms about her initial actions upon arrival at the scene, some assumptions had been made about her level of situational awareness and ability to gain the further necessary awareness, given the chaotic and rapidly evolving the event.398 393 Ex A5, pg. 133 394 Ex A5, pg. 839 395 Ex A5, pg. 841 396 Ex A5, pg. 847 397 Ex A5, pg. 851 & 852

398 T3-45 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 66 of 82

408. Inspector Cumming said that while she remained in command of the incident, Senior Sgt Browne was coordinating cordons and the like given his location and situational awareness, in accordance with legislation and QPS policy. The evidence of Snr Sgt Buxton was that the incident command followed policy and that the tactics developed were lawful, reasonable and appropriate.399

409. Upon Inspector Cumming arriving at the PFCP the SERT Tactical Commander was already forward establishing the inner cordon. She liaised with the SERT Commander after he told her the in accordance had been established.

410. With respect to establishing distal command and coordinating staff and resources while enroute, Inspector Cumming did not believe this to be appropriate as she did not have the requisite situational awareness.400

411. Inspector Cumming agreed that extending Incident Command training to other levels within the QPS, including different scenarios with field-based exercises, would be valuable.401 A refresher course for Inspectors and above ranking officers would also be beneficial to ensure those skills are kept up to date and any gaps in training are identified and filled.402

412. Inspector Cumming provided the following relevant evidence during the inquest:

• In terms of gathering information about what was transpiring at the scene, Inspector Cumming stated that it was ‘extremely challenging’. There was a great deal of radio chatter and the information on the iPad was slow to respond.

• In terms of coordinating staff while enroute to the scene, she noted that she did not consider that she had sufficient situational awareness to do so and could hear that Snr Sgt Browne was doing so at the scene.

• While she considered herself to be in command of the incident, Snr Sgt Browne maintained responsibility for coordinating the placement of crews in the cordon as he had greater situational awareness.

INVESTIGATION INTO LINKS BETWEEN BYATT AND MADDISON

413. A review of intelligence holdings and potential avenues of inquiry was undertaken by SC Flynn and Snr Sgt Davies.403

414. Following a thorough review, with the benefit of hindsight, SC Flynn failed to identify a link between the Wallers Road address, Adam Byatt or his associates in the police computer systems or via external agency checks. SC Flynn concluded that there were no obvious opportunities to identify the link between Mr Maddison and Mr Byatt prior to this incident.404

399 T3-3 400 T3-54 401 T3-55 402 T3-55 403 Ex A5, pg. 792 404 Ex A5, pg. 792 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 67 of 82

415. However, it was noted that police were made aware of a connection between Adam Byatt and the Wallers Road property on 11 May 2017 when a neighbour, an employee of the Lockyer Valley Regional Council, informed SC Brad Smart that the Wallers Road property was owned by Mr Byatt’s mother. Senior Constable Smart failed to enter this information on QPRIME. This was six days before SC Smart installed the Cuddeback camera opposite the property entry as part of the Gatton Police investigation into automatic weapons fire.

416. Senior Constable Flynn identified the siloing of information by Gatton Police in relation to reports of automatic gunfire led to significantly reduced situational awareness for other police. He indicated, even with the benefit of hindsight, it was difficult to reconcile all information related to this investigation. The earliest reports of automatic gunfire near the stronghold occurred in January 2017, and there was no follow up in relation to this report. Subsequent investigations identified that it was highly likely that there was automatic gunfire in the area, but officers failed to record this anywhere that was accessible by other police and failed to engage any specialist services for assistance.

417. An intelligence report should have been completed listing Mr Byatt as a named person/subject in the gunfire investigation and the stronghold flagged as such when SC Smart became of the belief that this was likely the location of the gunfire.

418. Mr Byatt’s family operated the Brightview Tavern in the Lockyer Valley. This is a 20 minute drive from Gatton. It would have been a simple task to make inquiries of the family, including Adam Byatt, in order to identify who was staying in the shed at 162 Wallers Road.

419. Senior Constable Flynn observed the two records relating to Mr Maddison’s possession of semi-automatic and automatic firearms (2007 and 2008) were not labelled as involving firearms. Nor was any firearms information contained in the summary. Failure to link and incorrect linking of subjects to the relevant intelligence submissions impeded the effectiveness of intelligence analysis.

420. Profiles had been completed of Mr Maddison by a variety of intelligence officers in relation to his domestic violence offending. Of these, only one provided any analysis or insight into Mr Maddison and the rest were simply QPRIME exports with nothing added.

Given the seriousness of the offending, and the risk to officer safety, a full and comprehensive profile of Mr Maddison should have been completed and this could have been updated each time a new version was requested.

421. A number of learnings were identified through this review, including the following:405

• All BOLO’s and Officer Safety Alerts should be subject to an assessment and approval by OIC or above.

• The failure to apply standardised information storage principles and the use of multiple file management systems are a hindrance to effective information management and necessitates a standardised file naming system.

• Review local reporting processes to ensure QPRIME is the point of truth and central reporting database for intelligence activities.

• Communication and link between systems utilised by QPS.

405 Ex A5, pg. 793 onwards Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 68 of 82

• Siloing of information to be overcome.

422. During the inquest, A/Inspector Davies gave evidence about the review conducted.406 He reiterated having interrogated the QPRIME holdings, ITAS, QCAD and the like, that there were no holdings of information that would have allowed officers to establish a relationship or link between Mr Maddison and Mr Byatt prior to 29 May 2017.407 He acknowledged that there was a high volume of information with respect to Mr Maddison that was contained across the various information systems within QPS. This took a week for intelligence officers to consider.408

423. A/Inspector Davies indicated that there were currently numerous programs being considered to see whether there is a way to automate linkages between the various QPS systems that contain information to ensure it is all captured and able to be accessed.409 He emphasised that QPRIME was intended to be the ‘point of truth’ with respect to recording information, and stressed the importance of a central database for police to access with respect to an offender to ensure all pertinent information is before the officer.410

CHANGES IMPLEMENTED BY THE QPS

424. In late 2018, an ‘On Road Supervisor’ Program was implemented in the Darling Downs District.411 The purpose of the role, filled by Sergeants and Senior Sergeants, was to provide on road supervision for the City and Country Patrol Groups.

425. During the course of the inquest, Superintendent Kelly agreed that a DDO would have assisted in responding to the critical incident, providing more cohesive control and oversight in terms of resources and management.412 A request had been made for a DDO in the region as a priority.

426. In late 2021, the QPS Deputy Commissioner for the Southern Region approved funding for five temporary Senior Sergeant positions to perform the role of District Duty Officer in the Darling Downs District by way of a 12-month trial.413 This trial was commenced on 1 January 2022 and will be evaluated with specific recommendations made for consideration to the Deputy Commissioner, Southern Queensland.

406 T9-32 onwards

407 T9-34 408 T9-45 409 T9-39 410 T9-40 411 Ex J43, [13]

412 T8-15 413 M Kelly Statement, dated 16.03.22 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 69 of 82

CONCLUSIONS ON INQUEST ISSUES The findings required by s.45 of the Coroners Act 2003

427. I am required to find, as far as possible, the medical cause of the deaths, who the deceased persons were and when, where and how they came by their deaths. As a result of considering all the evidence, including the material contained in the exhibits, I make the following findings: Brett Forte Identity of the deceased – Brett Andrew Forte How he died – Senior Constable Brett Forte died after he was shot by Ricky Maddison following a police pursuit culminating in a confrontation on Wallers Road, Ringwood. Mr Maddison had been able to avoid police detection for almost three months. He exited his vehicle, produced a rifle and immediately began firing a string of automatic gunfire. The gunfire penetrated the police vehicle being driven by SC Forte, who reversed rapidly. SC Forte was retrieved from the vehicle, while police remained under fire.

Unfortunately, despite medical intervention, SC Forte was declared deceased at 3:29 pm on 29 May 2017.

Place of death – Ford’s Road, Ringwood Date of death– 29 May 2017.

Cause of death – Gunshot and shrapnel wounds to the body.

Ricky Maddison Identity of the deceased – Ricky Charles Maddison How he died – Mr Maddison was wanted for arrest on offences of violence against his former partner and for breaching Domestic Violence Orders. Following a protracted siege, he died after Special Emergency Response Team Operators shot him after he opened fire upon Queensland Police Service officers with an automatic rifle.

Place of death – Wallers Road, Ringwood Date of death– 30 May 2017 Cause of death – Gunshot wound to the chest and abdomen.

Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 70 of 82

428. With respect to the other issues considered in this inquest I accept the submission on behalf of Susan Forte that the cause of her husband’s death should not be viewed only from the perspective of his fatal encounter with Ricky Maddison, after he was led to the entry to Maddison’s remote hideout on Wallers Road. SC Nielsen supported this submission.

429. I agree, with the benefit of hindsight, that there were several systemic factors that may have contributed to SC Forte’s death. It is possible, but not certain, that his death may have been prevented if those factors had been addressed.

430. In adopting a systemic approach, it is important to consider “not who blundered but how and why the defences failed”. This approach recognises that people are fallible, and errors are to be expected, even in the best organisations. However, errors are seen as consequences rather than causes. Their origins are “not so much in the perversity of human nature as in “upstream” systemic factors”. Countermeasures are based on the assumption that organisations can change the conditions under which people work and “build defences to avert errors or mitigate their effects”. 414

431. The prevalence of domestic violence in our society means that there will continue to be violent perpetrators in our community who are driven by a belief that their actions are justified. Like Mr Maddison, they will continue to be motivated to take revenge on victimsurvivors, and the police officers who endeavour to hold them to account.

432. The community should be able to have confidence that the QPS has the capacity to protect victim-survivors from dangerous perpetrators. Police officers engaged in this dangerous work should also have confidence that all reasonable steps are taken to ensure the QPS can deal effectively with outliers such as Mr Maddison.

Efforts to apprehend Mr Maddison

433. Mr Maddison was a well-known high-risk offender, who was wanted on warrants for serious domestic violence offences involving a firearm. He was undoubtedly dangerous and had evaded police for some time after living off-grid since early 2017. While Mr Maddison’s actions in opening fire on SC Forte and SC Nielsen with a fully automatic weapon were unprecedented in Queensland, his potential to inflict serious harm was unsurprising.

434. The risk he posed was clearly articulated in BOLO’s, Officer Safety Alerts, and other bulletins. It was well publicised in the police District. The high level of risk was highlighted by the decision to engage SERT in attempts to search and locate him before 29 May

435. A range of strategies had been engaged by the TCS to locate Mr Maddison. Those were very extensive, but appropriate given the charges for which he was wanted.

The police pursuit

435. I accept that the officers involved in the pursuit of Mr Maddison on 29 May 2017, including SC Forte and SC Nielsen, were aware of the high-risk Mr Maddison posed and that he may have access to firearms.

414 James Reason, Human error: models and management (2000) 320 British Medical Journal 768-770.

Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 71 of 82

436. There was a strong possibility any encounter with Mr Maddison would result in a tactically dangerous situation. This appears to have been anticipated by the officers involved, including SC Nielsen, who expected that some hands-on use of force would be required should he be apprehended. Caution was to be exercised in approaching Mr Maddison for these reasons. This was broadcast specifically by SC Forte during the pursuit.

437. Sgt Jenkins’ attendance at the Communications Room and discussions with the Comco during the pursuit were unusual. Sgt Jenkins and Snr Sgt Stahlhut asserted that this was done for the purpose of providing ‘reliable intelligence’ in relation to Mr Maddison.

438. As Sgt Douglas said that Sgt Jenkins’ presence informed his risk assessment in authorising the commencement of the pursuit, it is difficult to conclude that this decision was unreasonable, as was submitted by Mrs Forte. The concerns expressed by Snr Sgt Stahlhut and Sgt Jenkins about the need to apprehend Mr Maddison as a high-risk offender who had evaded police for some time, were confirmed by Sgt Douglas’ own inquiries in QPRIME.

439. However, it is not clear that Sgt Jenkins’ continued presence in the Communications Room as the pursuit developed was necessary or helpful. Steps have been taken to prevent such an occurrence from happening again at the Toowoomba Station.

440. The evidence provided by Sgt Douglas, and supported by the evidence of the radio communications during the pursuit, demonstrates that the decision to continue the pursuit was based on a continual risk assessment of the situation. Sgt Douglas based his assessment on the ongoing reports from those involved in the pursuit and it was clear it was not something he did lightly. The relevant factors mandated by the OPM in relation to the pursuit policy were applied appropriately.

441. I accept the conclusion reached by Det Snr Sgt Hinshelwood that the decision to commence and continue the pursuit of Mr Maddison’s vehicle (at least until he turned onto Wallers Road) was sound and complied with QPS policy. Further strategies were employed and planned to bring the pursuit to an end, including the use of Polair and the deployment of stingers.

442. I also accept the conclusion of Inspector Mowle in relation to the conduct of the pursuit.

He also found it complied with QPS policies. All relevant safeguards were employed, including a dedicated pursuit controller and restrictive use of force options were engaged.

443. I agree with Inspector Mowle’s conclusion that the absence of an officer with overall tactical command during the pursuit, with knowledge of Mr Maddison’s background and the police actions leading up to the incident, was a missed opportunity to provide proper overarching command.

444. This was a significant failure of leadership, particularly as senior officers in the Toowoomba Police Station knew that SERT had previously been tasked to arrest Mr Maddison and the engagement with him presented a very high risk to officer safety.

445. A tactical commander during the pursuit would have enabled the formulation and communication of an effective plan in line with previous threat assessments.

Unfortunately, no tactical plan or resolution was developed or communicated to all police involved in the pursuit. As was noted by Inspector Mowle, such a vital role could now be filled by a dedicated DDO in the region, which has been implemented on a temporary basis by the QPS.

Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 72 of 82

446. As they started to follow Mr Maddison along Wallers Road, which was in reality nothing more than a four wheel drive track, SC Forte and SC Nielsen both articulated their suspicion that he may be leading them somewhere. This was not communicated to the Comco.

447. Counsel Assisting submitted that SC Forte and SC Nielsen were equipped with the knowledge that Mr Maddison was a high-risk offender, who may be armed, but decided to continue the pursuit presumably while continually assessing the risk posed. SC Nielsen expressly stated during the inquest that she did not consider abandoning the pursuit as the more senior officer at the time.

448. However, I do not accept that it was reasonable to expect SC Forte and SC Nielsen to call off the pursuit on Wallers Road. They were clearly motivated to arrest Mr Maddison, but had no knowledge of Wallers Road or the surrounding terrain, including the fact that Mr Maddison’s capacity to exit the area in his vehicle was limited. Oversight from more senior officers was required, particularly as POLAIR and SERT were about to arrive to assist local police.

449. Given Mr Maddison’s profile and the high level of risk associated with engagement with him, an incident commander focussed on officer safety in the context of the possible use of firearms should have requested that officers ensured they were wearing protective body armour (ballistic vests) as envisaged by the relevant operational policies. Neither SC Forte or SC Nielsen were doing so. However, I note that the QPS issued protective body armour may not have been effective in the circumstances.415

450. The events that transpired when Mr Maddison exited his vehicle following a marked change in the terrain along the roadway had the hallmarks of an ambush. They were undoubtedly sudden, and prevented SC Forte and SC Nielsen from planning to retreat or withdraw. Notwithstanding, those actions might have been anticipated if appropriate tactical command was in place. That was not the role of the Comco.

451. Counsel Assisting submitted that I should accept Inspector Mowle’s view that even greater tactical command during the pursuit may not have prevented such a confrontation from occurring. Inspector Mowle thought it may have provided more clarity around tactics in terms of managing the ‘inevitable’ confrontation with Mr Maddison.

Unfortunately, the confrontation was left to evolve on Mr Maddison’s terms while SC Forte and SC Nielsen were, as SC Nielsen described, “sitting ducks”.

Knowledge of Mr Maddison and automatic weapons at the time of pursuit

452. During the inquest, a number of witnesses were asked about whether there was evidence Mr Maddison had access to automatic weapons.

453. Counsel Assisting submitted the only information available to police about Mr Maddison having possession of automatic firearms was from an unregistered human source who was interviewed by Snr Sgt Stahlhut in 2007, in which Maddison was referred to as “Matterson”.416 The source was subsequently interviewed, a search conducted, and no weapons were located.

415 Ex A5 – p 860

416 T6- 5 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 73 of 82

454. The intelligence report noted: “UHS is particularly concerned about Rick MATTERSON. He is in possession of numerous firearms including an SKK semi-auto 7.62 x 39 calibre which has had the firing mechanism modified to provide full automatic fire. This weapon has a 30 round magazine.”

455. The intelligence report was subsequently updated to note: “Rick MATTERSON is Ricky Charles MADDISON dob 13/12/1976”…. “MADDISON is a target of Operation Delta Rosetta.” ….

It is requested that this information is returned to the reporting officer for information.”

456. As previously noted, Snr Sgt Stahlhut told the inquest he never made a connection between Matterson and Maddison in relation to this intelligence, although he was the author of the intelligence report (the reporting officer) and had attended at the subsequent search of Mr Maddison’s Drayton residence, which included the removal of interior wall panels.417 He denied knowing when a link was made. He had several previous interactions with Maddison around 2007. He agreed he knew Mr Maddison was also a known ‘associate’ of the targets of Operation Delta Rosetta, but not a target himself.

457. Det Snr Sgt Hinshelwood told the inquest that the 2007 information was only located after a specialist intelligence officer was engaged to consider information for the purpose of the coronial investigation.

458. Det Snr Sgt Hinshelwood concluded there was no information available which would or should have enabled a link to be made between Mr Maddison and automatic weapons.

This was based on her assessment of what was known or ‘could have been known’ by the TCS or any other officers about Mr Maddison and the weaponry he had available at the time of the pursuit.

459. However, as Senior Constable Flynn observed, two records relating to Mr Maddison’s alleged possession of semi-automatic and automatic firearms in 2007 and 2008 were not labelled as involving firearms. Nor was any firearms information contained in the summary. I agree with his assessment that the failure to link and incorrect linking of subjects to the relevant intelligence submissions impeded the effectiveness of intelligence analysis in this matter.

460. Det Snr Sgt Hinshelwood’s report concluded that given the seriousness of the offending and the risk to officer safety, a full and comprehensive profile of Maddison should have been completed and this could have simply been updated each time a new version was requested.

461. The failure by relevant QPS officers to correctly record this information meant that it was not accessible to intelligence officers who were tasked to develop profiles on Mr Maddison for operational police. Unfortunately, as noted above, many profiles completed on Mr Maddison lacked analysis and were largely QPRIME exports.

417 Ex C279 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 74 of 82

462. In addition, it is difficult to accept that Snr Sgt Stahlhut did not make a connection between ‘Ricky Matterson’ and ‘Ricky Maddison’ in the context of the alleged possession of weapons when he was the author of the intelligence report. In those circumstances, I do not accept Det Snr Sgt Hinshelwood’s conclusion that there was no information available to enable a link to be made between Mr Maddison and automatic weapons before 2017.

463. However, I also accept that there was insufficient evidence produced at the inquest to suggest that Snr Sgt Stahlhut’s previous contacts with Mr Maddison, including the unsuccessful search for weapons a decade before SC Forte’s death, influenced or had any impact upon the manner or extent of attempts made by the QPS to apprehend Mr Maddison, including the conduct of the police pursuit.

Investigation into Automatic Gunfire at Ringwood

464. The Gatton Police investigation into the repeated reports of automatic gunfire at Ringwood was a missed opportunity to arrest Mr Maddison before SC Forte’s death. It is clear from the investigation conducted by ESC that there was a failure to respond appropriately, and the information provided was not evaluated and disseminated properly. The information was treated as relating to a licensed shooter using an illegal weapon for recreational purposes only.

465. Mr Maddison had unlawful possession of a Category R machine gun under the Weapons Act 1990. He faced a term of imprisonment of 7 years for this offence alone. He also faced a mandatory minimum term of imprisonment for possession of the muzzle loading pistol.

466. The reports of automatic gunfire at Ringwood coincided with Mr Maddison starting to live at Mr Byatt’s property on Wallers Road in early 2017. In my view, the Gatton Police did not treat those reports with sufficient urgency, even after an off-duty police officer who lived on Forestry Road called Policelink regarding automatic gunfire over a fifteenminute period on 17 April 2017. Direct Police contact with concerned residents was not made until that date, after another local resident recorded the automatic gunfire on her mobile telephone.

467. Gatton Police were advised on 11 May 2017 that the Wallers Road property was owned by the Byatt family. They were sent aerial images of the property by a Council employee.

Six days later they installed a Cuddeback camera opposite the entry to that property based on a suspicion that Adam Byatt was responsible for the gunfire. However, the camera was not fit for purpose and was engraved with the words “Gatton Police”. Gatton police knew Adam Byatt had some links to the Life and Death motorcycle gang but did not know of his connection with Mr Maddison.

468. The Cuddeback camera required a manual SD card to be extracted to check the captured footage. Other technology was available to live stream images from the location but was not utilised. The Cuddeback camera was easily located by Mr Maddison. It fuelled his hostility towards police and his suspicion that they had located his hideout. He assumed incorrectly that what was known by Gatton Police would have been shared with Toowoomba Police.

Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 75 of 82

469. No record of the Gatton Police investigation activities, including the suspected location of the automatic gunfire was placed on QPRIME. The information became siloed and limited the ability to apprehend Mr Maddison in a timely and safe manner. Intelligence officers were consequently prevented from reviewing the information and disseminating warnings to other police in Gatton and in neighbouring districts.

470. Advice was not sought from specialist units such as SERT, who have the capability to deal with armed and dangerous offenders in remote locations. Inspector Cumming was not advised and this prevented her from raising the issue at weekly District Planning Group meetings where priority taskings are discussed.

471. Gatton Police had established that the Wallers Road property was linked to the Byatt family after information was obtained from the Lockyer Council. An interview with the registered proprietor, Asia Byatt, would have established that her son’s friend son, Ricky, was renting the property from her. She had met Ricky and could describe him to police.

The next logical step might have been to interview Adam Byatt, who was the subject of SC Thaler’s intelligence report after he encountered him while hiking on Wallers Road on 18 May 2017, 11 days before SC Forte’s death.

472. In my view, it is likely that a more proactive approach by the QPS to the investigation of automatic gunfire at Ringwood would have resulted in Mr Maddison’s arrest, or at least a significant diminution of his capacity to enact his plans, had his hideout on Wallers Road been the subject of thorough police searches before 29 May 2017.

473. I agree with the submission on behalf of Mrs Forte that it is not possible to conclude with certainty that SC Forte, SC Nielsen or the Comco, Sgt Douglas, would have made the same decisions in relation to the pursuit of Mr Maddison along Wallers Road as its condition deteriorated if they were aware that there had been reliable reports of automatic gun fire in that specific location.

474. Information about automatic gunfire on Wallers Road at Ringwood could have formed part of the briefings all police officers tasked with arresting Mr Maddison were receiving, including the TCS officers who were not members of the Tactical Action Team. It could have been used in intelligence assessments and Officer Safety Alerts. Unfortunately, it was simply information that was not available to those officers.

475. I also agree that the assessment of Maddison’s risk as potentially being armed by SC Forte and SC Nielsen was more likely to have been influenced by his known possession of a “pirate pistol” rather than other high powered rifles.

Links between Mr Byatt and Mr Maddison prior to 29 May 2017

476. Counsel Assisting submitted that the findings of SC Flynn and Snr Sgt Davies that there was no evidence to link Adam Byatt and Mr Maddison prior to 29 May 2017 should be accepted.

477. I accept that apart from intelligence that both men had an alleged association with the Life and Death OMCG, this information was not available within QPS information holdings. I do not accept that there were “no obvious opportunities to identify the link between Maddison and Byatt prior to this incident”. As noted above, this information should have been identified in the Gatton Firearms investigation.

Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 76 of 82

478. In addition, three officers within the TCS knew about the connection between Adam Byatt, Wallers Road and the automatic gunfire investigation on 22 May 2017 after SC Thaler sent his email exchange with A/Sgt Smart to Snr Sgt Stahlhut and Sgt Curtain.

This information was not shared with other TCS officers.

479. It was recommended that given the volume of information across the various information systems within QPS in relation to Mr Maddison, a way to automatically link such systems would be beneficial. A number of options are being considered in this regard.

Incident Command

480. With respect to the adequacy of the incident command during the course of this event, I have been assisted by the QPS Incident Command Review. I accept that the event that was unfolding with respect to Mr Maddison, particularly immediately prior to and following the shooting of SC Forte, was chaotic and challenging.

481. Taking command of such a situation and gaining the necessary situational awareness would have been challenging, even for an experienced Police Forward Commander.

Notwithstanding, it was clear that Command activities were impeded by a lack of situational awareness from the outset of this incident, which impacted upon the effectiveness of the command and coordination of the police response.

482. This was hindered by a lack of SITREPS at the scene and the failure to establish a safe meeting point for crews responding to the incident, which also delayed the extraction of SC Forte. However, I accept that this delay was not outcome changing given the extent of the injuries suffered by SC Forte.

483. There was a general consensus during the course of the hearing from the officers called to give evidence that there was a need for ongoing and further scenario-based Incident Command Training for all levels of officers commencing at Senior Constable, including a refresher course for those in senior positions.

Siege and Mr Maddison’s death

484. It is clear from the evidence that after firing upon SC Forte and SC Nielsen the threat Mr Maddison posed given his ongoing course of conduct up until the time of his death was extremely high. Prolonged and extensive negotiation efforts and strategies were put in place during which he was offered the opportunity to surrender peacefully on multiple occasions. He chose not to comply. It was apparent from the note located at the stronghold, together with his conduct, weaponry and amount of ammunition that Mr Maddison had no intention of leaving the area alive.

485. With respect to the negotiations undertaken and siege management, I accept the findings of DSS Buxton, that all actions complied with the requisite siege management policies and procedures, including the decision to disable the vehicles.

486. The decision to fire upon Mr Maddison by the SERT operators was reasonable given the threat posed. I accept that lethal force was justified in this case.

Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 77 of 82

Adequacy of the police investigations

487. Counsel Assisting submitted that the police investigations into the deaths of SC Forte and Mr Maddison, conducted by DSS Hinshelwood and DSS Buxton respectively, were “professional and extensive”, identifying relevant shortcomings and seeking the necessary expert reviews as part of the investigations.

488. I agree that the content of both investigation reports was comprehensive and assisted in my task in making the necessary findings under s 45 of the Coroners Act 2003. The report into the death of SC Forte was over 800 pages in length.

489. However, as noted previously in these findings, the process of investigating SC Forte’s death ultimately led to the unfortunate circumstances set out in the Report of the Commission of Inquiry into Queensland Police Service responses to domestic and family violence. The Commission of Inquiry Report noted418: As a result of the matters outlined in Senior Constable Susan Forte’s affidavit [to the inquest] and the evidence given by Senior Constable Catherine Nielsen, a Senior Sergeant ESC investigator made a complaint against both officers for failing to report misconduct and a criminal charge of perjury. Both women were victims of serious criminal offending and were entitled to be treated accordingly. Further, the complaint was made while the inquest was still in progress and no findings had been made. In the Commission’s view, it was ill advised for the complaints to have been brought against either woman in these circumstances.

…..

Both officers should have been supported in raising reasonable concerns in the investigation, rather than being referred for poorly considered disciplinary proceedings.

490. I agree with those conclusions. Mrs Forte had set out her concerns about the circumstances of her husband’s death in interviews with ESC investigators in 2017 and subsequent correspondence. At the April 2021 inquest sitting, she also was directed by me to produce any further relevant information that was not already in evidence. Mrs Forte complied with that direction.

491. In my view it would have been unnecessary for such a direction to have been given if the ESC Report had dealt squarely with each of Mrs Forte’s concerns. The subsequent disciplinary action against Mrs Forte and SC Nielsen was also unwarranted, as was sharing the intention to commence disciplinary action against those officers with their family members before informing the officers.

492. SC Nielsen told the inquest that her life was made a ‘living hell’ for asking questions that were contrary to the QPS narrative after SC Forte’s death. She was threatened with disciplinary action. She no longer works in the TCS. While her obvious bravery on 29 May 2017 was acknowledged by the QPS, the subsequent process of the investigation into SC Forte’s death has obviously had a significant and damaging impact on her career.

418 At page 321 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 78 of 82

493. There was also a lack of clarity in relation to the roles of the respective ESC officers, particularly DI Hickey, as both investigators and family liaison officers. In those circumstances Mrs Forte was not provided with the support she might have expected as a serving police officer who had experienced the loss of her husband in such horrific circumstances.

COMMENTS UNDER SECTION 46 OF THE CORONERS ACT

494. In appropriate cases, a coroner can comment on anything connected with a death investigated at an inquest that relates to the administration of justice, public health or safety or ways to prevent deaths from happening in similar circumstances in the future.

The power to make recommendations should be construed liberally. As Muir J confirmed in Doomadgee v Clements419: The expressions “connected with” and “relates to” are of wide import and connote a connection or relationship between one thing and another. The closeness of the connection or relationship is to be “ascertained by reference to the nature and purpose of the provision in question and the context in which it appears”. The expressions are “capable of including matters occurring prior to as well as subsequent to or consequent upon” as long as a relevant relationship exists.

The purpose of s 46(1)(c) is self-explanatory. The purpose of the other two paragraphs of the subsection is to empower the Coroner to address the topics specified in them with a view to exposing some failing, deficiency or wrong and/or suggesting measures which may be implemented for the public benefit.

495. I have considered the submissions of Counsel Assisting, Mrs Forte and the Commissioner in relation to possible comments under s 46 of the Act in the context of the evidence provided during the inquest and my conclusions on the inquest issues.

496. I agree with the submission from the Commissioner that there was insufficient evidence before the inquest for me to make the recommendation sought in Mrs Forte’s submission in relation to the supply of police rifles and training in their use. I was not able to make a considered assessment of that issue. However, I note that the Commissioner has submitted that the QPS will continue to review its practices for the supply of accoutrements to police officers.

497. Similarly, Mrs Forte submitted that consideration should be given to the formation of a High-Risk Domestic Violence Unit in the Darling Downs District, similar to those that have been implemented in the Mount Isa and Gold Coast regions. Mrs Forte’s submission acknowledged that a Vulnerable Persons Unit had been established within the Darling Downs District. SC Nielsen also submitted that the Vulnerable Persons Unit in Toowoomba should be maintained and adequately staffed.

498. There was insufficient evidence before the inquest for me to make a considered recommendation about a High-Risk Domestic Violence Unit in Toowoomba. High Risk Teams are established and supported by the Department of Justice and AttorneyGeneral. They include representatives from agencies including specialist services, the QPS, health and Queensland Corrective Services. As the Commissioner’s submission noted the Women’s Safety and Justice Safety Taskforce recommended that the “Queensland Government continue to roll out integrated service system responses and High-Risk Teams in additional locations”.

419 [2006] 2 Qd R 352 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 79 of 82

499. The Queensland Government response to that Taskforce recommendation notes that the Government has committed to undertaking detailed analysis of the High-Risk Team model and funding structure “to ensure HRTs are adequately resourced, interconnected and appropriately equipped to meet existing and emerging needs in the community. As part of this analysis, consideration will be given to regions where there is unmet demand to inform decision-making for the locations of additional Integrated Service Responses and HRTs across Queensland”. The roll-out of several new High Risk Team locations was announced in the second half of 2022.

500. The inquest did not consider broader issues relating to the QPS response to domestic violence. Those matters were comprehensively considered in the Independent Commission of Inquiry into Queensland Police Service responses to domestic and family violence, and the subsequent A Call For Change Report. Recommendation 7 of that Report has been accepted by the Queensland Government. It was as follows: Within 18 months, the Queensland Police Service establish a Domestic and Family Violence Vulnerable Persons Unit in each district, which, at a minimum, maintains a 24 hours per day, seven day on call response capability and includes High Risk Team members, Domestic and Family Violence Coordinators, detectives to investigate domestic and family violence occurrences, and, where practicable, domestic and family violence support workers from community organisations.

Training in Incident Command

501. Counsel Assisting submitted that I consider recommending the QPS implement further regular scenario and team based Incident Command Training. Similarly, SC Nielsen submitted that the QPS should implement and maintain policies and procedures which reflect best practice in relation to overall tactical command and planned approaches to apprehension.

502. I am not satisfied a further recommendation on those topics is required as they have been considered in a number of previous inquests.

503. As the Commissioner's submission noted, this issue was most recently considered in the 2022 Findings of the inquest into the death of Duy Linh Ho. In that inquest I accepted that the training currently provided to officers in relation to incident command was extensive.

504. The Leadership Capability Program commenced in January 2022 and provides incident command training to selected officers. The QPS also has a “Regional Incident Command Training – Train the Trainer” program. This program equips officers to deliver two day Regional Incident Command Training to officers who may be required to perform the role of a forward commander.

Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 80 of 82

District Duty Officer in the Darling Downs District

505. All police officers called during the inquest agreed that the DDO role is critical in providing overall management and leadership during critical incidents.

506. The submission from the Commissioner noted that a 12-month trial420 for the DDO position in the Darling Downs District commenced on 1 January 2022 and would be evaluated with specific recommendations made for consideration by the Deputy Commissioner, Southern Region. I understand that those DDO roles are still funded on a temporary basis.

507. Mrs Forte and SC Nielsen both submitted that the current temporary arrangements should be made permanent.

Recommendation 1 I recommend that the QPS permanently establish District Duty Officer positions in the Toowoomba District at the level of Senior Sergeant.

QPS information systems

508. It was clear from the evidence in the inquest that important information relating to matters such as Mr Maddison’s weapons history and the investigation into automatic gunfire at Ringwood was not accessible to frontline police officers, who were required rely on systems such as QPRIME in assessing risk and planning operations. This was because the information had been incorrectly labelled, entered into the wrong system or there was a fundamental failure by officers to enter any relevant information on QPRIME.

509. Counsel Assisting submitted that I consider recommending that the QPS continue and expedite efforts to find a suitable system that can automatically link the information systems within the QPS in order to ensure a central database is available for all police to access with respect to a particular offender.

510. Mrs Forte submitted was that the QPS should implement a centralised intelligence database as a matter of urgency, together with mandatory ongoing intelligence database management training. This was supported by SC Nielsen.

511. The Commissioner noted that Acting Inspector Davies had given evidence that the QPS was examining how to automatically link the various information systems that are accessible by police officers. The Commissioner’s submission noted that the QPS will continue to investigate the availability of suitable technology solutions that could provide a “federated search engine” with the view that such a solution could achieve the linking of various QPS databases.

Recommendation 2 I recommend that, as a matter of priority, the QPS implement a solution to enable searches to occur across all QPS information systems and intelligence holdings to ensure frontline officers have access to reliable and current information.

420 M Kelly Statement, dated 16.03.22 Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 81 of 82

The QPS should report on its progress in relation to the implementation of this recommendation within six months.

Recommendation 3 I recommend that the QPS ensure that all officers are regularly trained in relation to their obligation to enter intelligence information correctly within relevant QPS databases in a timely manner and the ongoing management of those databases.

Responding to reports of gunfire

512. The presence of unregistered automatic weapons in the community is an obvious matter of concern. The investigation by Gatton Police into reports of automatic gunfire at Ringwood was the subject of consideration in this inquest.

513. Chief Superintendent Kelly outlined how he subsequently implemented a structured approach to the investigation and assessment of reports of “shots fired” in the Darling Downs District. This includes a monthly intelligence assessment and a full review of all shots fired incidents to ensure appropriate attendance, investigation, reporting and escalation through the chain of command. While this approach appears to have been effective in the Darling Downs District, it is not clear that it has been implemented in other police districts.

Recommendation 4 I recommend that the QPS consider implementing a State-wide instruction in relation to Firearms Assessments as a mechanism to review shots-fired incidents with clear expectations in relation to the investigation of those incidents and associated reporting requirements. This might be modelled on the approach taken in the Darling Downs District.

514. I close the inquest.

Terry Ryan State Coroner

BRISBANE Findings of the inquest into the deaths of Brett Forte and Ricky Maddison Page 82 of 82