MOLAYEE, Omid

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Omid Molayee TITLE OF COURT: Coroners Court JURISDICTION: Brisbane FILE NO(s): 2020/1453 DELIVERED ON: 17 November 2023 DELIVERED AT: Brisbane HEARING DATE(s): 30 May 2022, 5-9 December 2022 FINDINGS OF: Terry Ryan, State Coroner CATCHWORDS: Coroners: inquest, death in custody, police shooting, self-immolation in vehicle, Public Safety Response Team, incident command, domestic violence.

REPRESENTATION: Counsel Assisting: Ms R Helsen Molayee family: Mr M Rawlings instructed by Caxton Legal Centre QPS officers: Mr C Gnech, Gnech and Associates

Senior Constable Chand: Ms R Tierney, Gilshenan and Luton Det Sgt Downey: Ms S Ford, Gilshenan and Luton Commissioner of Police: Mr M O’Brien, QPS Legal Unit

Contents

Introduction

1. Omid Molayee was 43 years of age at the time of his death. He died on 6 April 2020 after he was shot by police in the carpark of the McDonald’s restaurant at Sunnybank in Brisbane after setting himself alight and running at police. Earlier that evening he had poured petrol over himself and his partner and threatened to set his partner and himself alight at her home at Sunnybank. He had also threatened to harm police.

The inquest

2. Mr Molayee’s death was deemed to be a ‘death in custody’ under the Coroners Act

2003. An inquest was required by s 27 of the Coroners Act.

3. Following a pre-inquest conference on 30 May 2022 the issues for the inquest were determined to be as follows:

• The findings 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.

• The circumstances leading up to the shooting of Mr Molayee by Police on the 6 April 2020.

• The appropriateness and sufficiency of the actions by the attending police officers on 6 April 2020 in relation to Mr Molayee, including but not limited to, the tactical strategy employed, effectiveness of the negotiations conducted and the decision by police to use lethal force.

• Whether the police officers involved acted in accordance with the Queensland Police Service (QPS) policies and procedures then in force and whether their actions were appropriate.

• Whether the training provided to officers in responding to a similar incident is sufficient.

• The adequacy of the investigation into the death conducted by officers from the Queensland Police Service (QPS) Ethical Standards Command.

4. The inquest was held from 5-9 December 2022 and 19 witnesses were called to give evidence.

Inquest into the death of Omid Molayee Page 1 of 30

The evidence Personal history

5. Mr Molayee was born on 22 September 1976 in Iran. Department of Home Affairs records indicate that he illegally entered Australia by boat in April 2011.1 His family, including his daughter from a previous marriage, remained in Iran. On 24 January 2012, he was granted a Protection Visa that allowed him to remain in Australia.2

6. At the time of his death, Mr Molayee lived with his partner, Ms Pooyan, and her three children at Wynne Street, Sunnybank. They had been in a relationship for several months after meeting online. Mr Molayee moved from South Australia in December 20193 and he immediately started living with Ms Pooyan, a Kurdish speaking woman from Iraq.

7. Mr Molayee had no recorded criminal history. However, four police incidents were recorded in both New South Wales and South Australia. The incidents in South Australia related to a missing person report, a major collision, and domestic violence.4

8. Medical records indicated that Mr Molayee had admitted to occasional drug use in the past. He also suffered from depression and anxiety and was referred to a psychologist for treatment in 2013.5 Interviews conducted with previous partners for the purpose of the coronial investigation revealed he exhibited concerning coercive controlling and paranoid behaviours. His partners expressed concern for his mental health.

Family statement

9. A family statement provided to the Court by Mr Molayee’s family reflected that that he was a father, a son and a friend. He was a man of dignity and of pride. He was devoted to making a better life for his daughter, Roza. The statement said that Roza is filled with the anger that comes from “suddenly and enigmatically losing her father”. His parents also “confront the confusion of a loss which is both foreign and heartwrenching.”

10. Mr Molayee worked in South Korea before committing himself to the journey to Australia by boat. He was caught up in our immigration system when he arrived in Australia. The statement said he fought to be a part of a society with democratic values, a life far removed from Iran. He loved his time in Australia, built a life and made this country his home.

11. Mr Molayee’s family said that he was close to his parents, despite the distance. He shared his life in his new country by “regaling them with stories of his friends, work and adventures. They did not feel the impact of distance, and always cherished those stories. He is missed every day”.

1 Ex A5, pg. 63 2 Ex A5, pg. 63 3 Ex A5, pg. 4; Ex B1, [5] 4 Ex A5, pg. 64; Ex C19-C23 5 Ex A5, pg. 65 Inquest into the death of Omid Molayee Page 2 of 30

12. Mr Molayee’s family said there was no opportunity to say goodbye. Roza is left to find her way in a world without her father, without the peace of understanding why his life ended in this way, and the anger of knowing she will not see him again.

13. The statement said that the Court must consider the details of the lowest moment, on the darkest day, of a man whose “life was dedicated to dignity and honour. Please do not lose sight of the man he was. His family will never forget him.” Events leading to the Death Domestic violence incident – threats of immolation

14. On the evening of 5 April 2020, Mr Molayee and Ms Pooyan had an argument. Ms Pooyan was accused of being unfaithful. Mr Molayee told her he was ending the relationship and returning to South Australia.6

15. Early the following morning, at around 5:00am, Ms Pooyan left for work on the Gold Coast while Mr Molayee was asleep.7 At 2:00pm, while she was returning home from work, Mr Molayee contacted her and asked her to buy him an energy drink. This was the first contact they had on that day.

16. When Ms Pooyan arrived home at around 2:40pm, Mr Molayee asked that she speak to him in the bedroom.8 He demanded that she swear on the Qur’an that she was not cheating on him. Ms Pooyan then indicated that she wanted to end the relationship.

She asked him to leave as soon as COVID-19 related restrictions on interstate travel were lifted.9

17. Mr Molayee remained in the bedroom while Ms Pooyan spent the evening in the living room. At around 8:45pm, she went to bed. Mr Molayee then asked if she would reconsider and if they could continue the relationship.10 When she refused, Mr Molayee locked the bedroom door and poured petrol on himself, Ms Pooyan, the carpet, and the bed.11

18. Ms Pooyan recalled that he was visibly angry and holding a lighter. Mr Molayee said, ‘I am just going to set us both on fire’.12 Ms Pooyan pleaded with him to calm down before he grabbed her by the left hand.13 She managed to escape his grip and leave the bedroom. She sought help from her oldest son, who called 000 for assistance at 9:01pm.14

19. Despite attempts to stop him, Mr Molayee fled the residence in his silver Holden Astra.15 Ms Pooyan recalled that he was covered in fuel when he drove away.

However, he did not take a fuel container with him.16 6 Ex B1 7 Ex B1, [34] 8 Ex B1, [40] 9 Ex B1, [47] – [50] 10 Ex B1, [53] 11 Ex B1, [55] 12 Ex B1, [57] 13 Ex B1, [58] 14 Ex B1, [62] – [65] 15 Ex B1, [65] 16 Ex B1, [66] Inquest into the death of Omid Molayee Page 3 of 30

20. At 9:03pm, the Police Communications Centre dispatched a broadcast for any available crews to attend Wynne Street, Sunnybank as a code one priority job. South Brisbane District Crews SC441, consisting of Senior Constable Godsall17 and Constable Keating18 and SC402, consisting of Senior Constable Chand and Constable Sandhu, responded and proceeded to the address. Constable Sandhu was a first year constable with only four months service and SC Chand was his field training officer.

21. The Queensland Ambulance Service (QAS) and Queensland Fire and Emergency Services (QFES) were also advised and attended.

22. SC441 and SC402 arrived at the residence at 09:09pm. According to SC Godsall and Constable Keating, Ms Pooyan smelt strongly of petrol, as did the bedroom in the residence. QFES attended and determined that there were minimal flammable particles in the bedroom.19 They also assessed Ms Pooyan and advised her to remove the clothing she was wearing.20

23. At around 9:10pm, while police were speaking to Ms Pooyan with the assistance of her son as translator, Mr Molayee called and had a conversation with her in Kurdish, which was translated into English for the police by family members.21 Constable Keating told the inquest he started working on a Police Protection Notice on his QLite device.

24. At 9:13pm, SC Chand broadcast over the police radio: The person of interest is on the telephone with the occupant of this address and stated that he will come here and put petrol on himself and set fire in front of the police.

He’s on the phone with us at the moment, he said he’s going to set himself on fire in front of the police.22

25. SC Godsall recalled asking Ms Pooyan and her son whether Mr Molayee understood and spoke English. They advised that he did and would understand well enough to be able to comply with any police directions. This was relayed to Police Communications.23

26. At 9:13pm, the QPS Communications Coordinator asked for assistance from Polair to help locate Mr Molayee’s vehicle. Polair indicated they would standby, pending the outcome of the proposed triangulation of his mobile telephone.

27. SC Chand and Constable Sandhu left the address to conduct patrols for Mr Molayee’s vehicle.

28. At 9:19pm, two crews from the Public Safety Response Team (PSRT) ZE790 and ZE791 also proceeded to the location to commence patrols. Both teams were aware that Mr Molayee had doused himself in fuel and threatened to set himself alight.

17 Ex B5 18 Ex B6 19 Ex B5, [8] 20 Ex B5, [9] 21 Ex B6, [19]; [21] 22 Ex B5, [12]; Ex B6, [21] 23 Ex B5, [14] Inquest into the death of Omid Molayee Page 4 of 30

29. Crew ZE791 consisted of SC Shepherd (team leader)24 and SC Cheung-Fook.25 They devised a plan in transit that if they encountered Mr Molayee’s vehicle, they would ‘push up’ onto the vehicle to contain it.26 A 40-millimetre single shot launcher that fired less lethal rounds was available to them, as well as a riot shield. It was proposed that SC Cheung-Fook would be at the front with a riot shield and SC Shepherd would be off to the side with the rifle.27 They intended to commence negotiations with Mr Molayee.28

30. PSRT Crew ZE790 consisted of SC Holt (team leader),29 SC Collander30 and SC Manson.31 The plan discussed by the team was to prevent Mr Molayee from setting himself alight. It was decided that SC Manson would be in possession of a fire extinguisher, which she had in her hands in transit.32

31. SC Holt directed his team that, ‘even if he wasn’t on fire, but he was doused in petrol we were still going to deploy the fire extinguisher and try to get any lighters out of his hand before he could actually light himself on fire.’33 SC Holt was to be armed with a 40-milimetre revolving pump action weapon that fired less than lethal rounds. SC Collander described the plan formulated by SC Holt as the containment of Mr Molayee’s vehicle and negotiation of a surrender.

32. In transit, discussions were had between SC Shepherd and SC Holt as to how they would approach Mr Molayee.34 SC Shepherd was the most senior officer in the two PSRT vehicles.35 It was confirmed that crew ZE790 had also prepared the riot shield and less lethal force options and planned to triangulate and move into a position to negotiate. They described discussing ‘the best and safest option was de-escalation and less than lethal confrontation’.36

33. A be on the lookout (BOLO) was broadcast for crews to look out for Mr Molayee’s vehicle. Other crews in the area commenced conducting patrols.

34. At 9:24pm, the Communications Coordinator advised that the triangulation results on Mr Molayee’s mobile number had identified that ‘he is on the north-eastern side of Pinelands and Beenleigh Road intersection’.

35. At 9:37pm, SC441 transmitted, ‘update POI threatening to set himself on fire if we approach’. A further transmission was then made, which stated ‘he can allegedly see some police vehicles nearby, so police with moving patrols please be extra vigilant’.

24 Ex B27 25 Ex B28 26 Ex B27, pg. 43 27 Ex B27, pg. 43 28 Ex B27, pg. 44 29 Ex B30 30 Ex B26 31 Ex B29 32 Ex B29, pg. 8 33 Ex B30, pg. 66 34 Ex B27, pg. 44 & 45 35 Ex B27, pg. 45 & 46 36 Ex B27, pg. 44 & 45 Inquest into the death of Omid Molayee Page 5 of 30

Mr Molayee’s vehicle is located

36. SC Chand and Constable Sandhu were patrolling and approached the driveway to the McDonalds carpark at Times Square, 240 McCullough Street, Sunnybank. They saw Mr Molayee’s vehicle in the carpark.

37. CCTV footage from McDonalds showed Mr Molayee driving into the carpark from the Zamia Street entrance and reversing his vehicle into a car space. The iLoad van driven by Constable Sandhu was captured on the footage entering the carpark.

38. SC Chand could see that Mr Molayee was seated in the front driver’s seat of the parked vehicle, winding up his windows. Constable Sandhu parked the police vehicle in front of Mr Molayee’s vehicle.

39. At 9:45pm, Ms Pooyan received a call from Mr Molayee who told her that he had two police cars around him and ‘if they try anything, I am going to set myself and the Police Officers on fire’.37 She told him not to as the Police were there to help him. He stated, ‘No I know what the Police are going to do with me. You are not going to see me again, goodbye’.38

40. S/Sgt Manning Jones was the Centenary District Duty Officer (DDO) that evening and recalled that around 9:30pm he was briefed on the incident.39 He requested further triangulation take place of a secondary number being used by Mr Molayee to contact Ms Pooyan.

41. At 9:59:49, a radio transmission was made by SC402 confirming they had located Mr Molayee: ‘We are currently with the POI. He has locked himself in. He’s got fuel and he’s making threats to kill himself. We need QAS here urgently’.

42. SC402 subsequently transmitted their position. S/Sgt Manning Jones advised the radio chatter was ‘very busy’ that evening. However, he advised Communications to contact QFES given the threats made by Mr Molayee.40

43. After SC Chand approached the driver’s side door of the Astra, Mr Molayee raised his hands. He was holding a container of fuel in one hand and a lighter in the other. Mr Molayee told SC Chand to ‘back off’ and both officers stepped back from the vehicle.

Constable Sandhu recalled that Mr Molayee said, “you can’t save me”.

44. SC Chand and Constable Sandhu sought urgent assistance from QAS, QFES and QPS at their location. They asked that responding crews proceed with no lights and sirens as the situation was currently calm.

45. SC Chand attempted to engage in negotiations with Mr Molayee through the driver’s side of the vehicle. During this time, Mr Molayee was winding his window up and down intermittently.

37 Ex B1, [69] 38 Ex B1, [71] 39 Ex B23, [4] & [5] 40 Ex B23, [8] Inquest into the death of Omid Molayee Page 6 of 30

46. Mr Molayee was reported as saying words to the effect, ‘I’ve lost everything. I lost my wife, I lost my daughter, and the government has taken my money and I’m going to kill myself’.

47. SC Chand tried to reassure Mr Molayee, making comments such as, ‘Mate, I’m here to help you. I’m your point of contact. I will keep talking to you. Nobody will touch you, I will talk to you straight myself’.

48. At this time, the PSRT officers were traveling in a convoy to the scene, with ZE791 as the lead vehicle. They booked off via the police radio at McDonalds at 10:03:07pm. SC Holt, SC Collander, SC Manson, and SC Cheung-Fook activated their BWC, which captured the remaining part of the incident as it unfolded.

49. Vehicle ZE791 was positioned to the left of Mr Molayee’s vehicle to provide some containment. This vehicle was fitted with a dashcam, that did not record sound but captured the incident. SC Cheung-Fook retrieved a baton from the rear of his vehicle41 and SC Shepherd moved towards the rear of Mr Molayee’s vehicle so he could get into position and ‘assist with negotiations’.42

50. A dashcam capture from ZE791 showed the scene as the vehicle arrived. SC Chand can be seen attempting to engage with Mr Molayee as he remains seated in his vehicle.

Constable Sandhu is standing next to SC Chand.

51. SC Chand told the inquest he was trying to buy time in negotiating with Mr Molayee, who told him to move back. However, he also “knew that something would happen”.

SC Chand said that he was in command at that time and he thought Mr Molayee had been contained to enable negotiations to proceed.

52. PSRT vehicle ZE790 was initially parked on Zamia Street, Sunnybank at the rear of Mr Molayee’s vehicle and was partially obscured from view. SC Holt instructed SC Collander to stop at this location so they could approach the vehicle from the rear and assess the situation.43

53. Behind the PSRT vehicles was a marked Police SUV with SC Day and SC Wilcox,44 who had heard the job and location over the radio.45 They parked their vehicle in Zamia Street, facing a westerly direction opposite Mr Molayee’s vehicle, which was approximately 20 metres away.46 The officers exited their vehicles and retrieved a fire extinguisher from the boot, before approaching Officers Chand and Sandhu.47

54. The PSRT officers exited their vehicles while SC Chand was speaking to Mr Molayee.

SC Holt and Constable Manson were positioned at the rear of Mr Molayee’s vehicle partially obstructed by bushes.48 41 Ex B28, pg. 17 42 Ex B27, pg. 19 43 Ex B30, pg. 21 44 Ex B8 45 Ex B7, [9] – [12] 46 Ex B7, [20] 47 Ex B7, [20] 48 Ex B29, pg. 12-15 Inquest into the death of Omid Molayee Page 7 of 30

55. ZE791 transmitted a request over the radio for ZE790 to reposition their vehicle to provide further containment of Mr Molayee to limit his ability to decamp from his vehicle. As a result, SC Collander drove the vehicle towards the entrance of the carpark off Zamia Street.

56. When asked why the PSRT vehicle did not remain about of sight, SC Shepherd said that the risk posed by Mr Molayee was enormous if he left the scene as he had a container of fuel he could have used as a weapon. The mission was to prevent Mr Molayee from using the fuel to ignite himself or others - to isolate and contain. This required tight containment of Mr Molayee’s vehicle. SC Shepherd said that this was not a planned operation and it was necessary to allocate roles on the way to the scene.

57. SC Cheung-Fook said that if Mr Molayee left in his vehicle, it would constitute a mobile stronghold and the risk of injury could not be mitigated, referring to missed opportunities to stop the offender’s vehicle in the January 2017 Bourke Street tragedy.

The containment was intended to provide a safe platform for negotiation. He said PSRT officers were in attendance as a “force multiplier”.

58. At this time, Mr Molayee was observed moving inside his vehicle. SC Chand stated, ‘no, no, no don’t do that’. Mr Molayee subsequently lifted a container and poured fuel over his head and body and appeared to strike a lighter, which failed to ignite.49 SC Chand then attempted to break the driver’s window with a baton, but was unsuccessful.

SC Chand considered that Mr Molayee “lost focus” when he saw the PSRT teams arrive and said “I’m going to kill myself”

59. SC Holt and SC Manson moved forward when Mr Molayee doused himself in fuel, and as SC Chand struck the window with a baton. The vehicle and Mr Molayee burst into flames and SC Holt used a reaming tool to smash the driver’s window. The vehicle and Mr Molayee were engulfed in fire at this point. SC Manson deployed a fire extinguisher.

However, it only expended retardant for a few seconds and the fire was not extinguished.50

60. SC Collander was in the process of driving the PSRT vehicle ZE790 into the carpark and was not aware of the events that unfolded. He saw Mr Molayee’s vehicle was fully alight.51

61. SC Holt ran to ZE790 in an attempt to locate another fire extinguisher. SC Chand attempted to open Mr Molayee’s driver’s side door, but he was pushed back by flames.

The increasing intensity of the fire forced officers to step further away from the vehicle.

49 Ex B27, pg. 22; Ex B29, pg. 13-15; Ex B30, pg. 23 50 Ex B29, pg. 17-20 51 Ex B26, pg. 25-27 Inquest into the death of Omid Molayee Page 8 of 30

Mr Molayee exits the vehicle

62. Approximately 15 seconds after the vehicle caught alight, Mr Molayee opened the driver’s door. He was engulfed in flames and immediately ran towards police.

63. The events that transpired after Mr Molayee exited the vehicle happened within 10 seconds. They were captured on the BWC footage of SC Holt, SC Collander, SC Manson, and SC Cheung-Fook. A civilian also recorded the encounter from a distance.

CCTV footage from McDonalds, while recovered, was distorted and unable to be restored.

64. SC Chand said he recalled Mr Molayee running towards him. He tactically repositioned himself as he believed that Mr Molayee was attempting to grab him. Mr Molayee ran after him and he was fearful for his life. He said that he had been affected by this incident he would not change his actions and that he did his best to resolve the incident.

65. The BWC footage of SC Holt shows Mr Molayee rush from his vehicle towards SC Holt who moves backwards. He called repeatedly on Mr Molayee to ‘get back’.52 He continued to run at SC Holt, who deployed a less than lethal 40-millimetre weapon containing six rounds, similar to bean bag rounds.53 SC Holt observed Mr Molayee change direction and apparently run at another officer.54

66. According to SC Manson, Mr Molayee was fully alight at the time he charged at her with his hands out.55 She slipped slightly, turned, and ran to the rear of the PSRT vehicle. She saw SC Holt deploy the sponge rounds, which appeared to hit Mr Molayee.

67. Constable Sandhu observed Mr Molayee exit the vehicle and start running. He got very close to SC Chand. Mr Molayee then ran at him and another PSRT officer.

68. SC Shepherd said he observed Mr Molayee running alight towards other officers near the walkway, before Mr Molayee ran back towards him. He also deployed a less than lethal 40-millimetre weapon containing one round.56

69. SC Cheung-Fook observed SC Shepherd deploy the less than lethal round and described the rounds bouncing off Mr Molayee. He formed the view that Mr Molayee was ‘searching for who was closest’.57 He then moved forward with a riot shield to use as protection with the intention of taking Mr Molayee to the ground.

70. Each of the officers expressed the view that the less than lethal rounds were ineffective in stopping Mr Molayee from running at police while alight.

71. SC Collander exited the driver’s side of ZE790, and upon hearing the request for a fire extinguisher from SC Holt, moved to the rear of the vehicle. He was unable to locate a fire extinguisher. As he moved to the front of the vehicle, he was positioned between SC Holt and SC Cheung-Fook. He said that he saw Mr Molayee extract himself from the vehicle and run in the direction of police.58 52 Ex B30, pg. 24 & 25 53 Ex B30, pg. 25 54 Ex B30, pg. 38 55 Ex B29 56 Ex B27, pg. 35-37 57 Ex B28, pg. 24 58 Ex B26, pg. 45 Inquest into the death of Omid Molayee Page 9 of 30

72. SC Collander saw that the less lethal use of force options engaged had been ineffective in stopping Mr Molayee’s ability to run at police officers with ‘bear hug arms’.59 He saw Mr Molayee run at SC Chand as that officer was trying to run away from him.

73. When SC Chand changed direction and ran back towards the vehicle, Mr Molayee appeared to follow him. At this time, SC Collander moved towards the front of the PSRT vehicle and could see Mr Molayee running at a number of officers. He heard directions being provided by the officers to Mr Molayee, to ‘get on the ground’.60

74. SC Collander formed the view that the police officers were in immediate danger of death or grievous bodily harm. He discharged four rounds from his service weapon at 10:04:13pm.61 He did not recall saying anything before discharging his weapon.

However, this does not correlate with his BWC, which suggested he provided the command ‘on the ground’.62

75. Mr Molayee sustained two gunshot wounds and fell to the ground. Police subsequently deployed two fire extinguishers directly at Mr Molayee to extinguish the flames and moved him away from the burning vehicle.

76. The Queensland Ambulance Service (QAS) was immediately on the scene, having staged at Zamia Street. The QAS provided immediate first aid as soon as the fire was extinguished.

77. The QFES arrived on the scene approximately 90 seconds after Mr Molayee was shot and extinguished the burning vehicle. Mr Molayee was conveyed to Hospital, but the QAS stopped on Mains Road Sunnybank to meet with the High Acuity Response Unit and the QAS Medical Director, Dr Rashford. Extensive intervention and treatment of Mr Molayee continued in transit until he was pronounced deceased on 6 April 2020 at 10:37pm.

78. Dr Rashford provided a detailed report on the events of that evening and his emergency intervention given the grave prognosis for Mr Molayee and the multiple lifethreatening injuries he sustained.63

79. A statement was obtained from Acute Care Paramedics, Ms Blackman and Ms McKenzie. They were coincidentally at the scene when the events unfolded and saw police engaging with Mr Molayee. ACP Blackman indicated that when she saw he was engulfed in flames she prepared equipment to respond.

80. Ms Blackman stated she was ‘terrified’ for the police as Mr Molayee appeared to be running at them with purpose while screaming and on fire.64 Immediate assistance was provided by ACP Blackman and Ms McKenzie after the fire was extinguished.65 Ms McKenzie described seeing Mr Molayee ‘trying to attack police’. She said that he charged at different officers.66 59 Ex B26, pg. 27-29; 45; 51 60 Ex B26, pg. 62 & 63 61 Ex B26, pg. 65 (and throughout) 62 Ex B26, pg. 61 & 62; Ex A5, pg. 81 63 Ex D1 and D2 64 Ex B15, [17] & [18] 65 Ex B15, [23] 66 Ex B16, [16] Inquest into the death of Omid Molayee Page 10 of 30

81. A crime scene was immediately declared and a log created. A secondary crime scene at Wynne Street, Sunnybank was declared at 11:20pm.

82. The DDO, S/Sgt Manning Jones, attended the scene after Mr Molayee had been removed from the area.67 He recalled having a conversation with SC Chand who appeared distressed. SC Chand told him:68

• When he located Mr Molayee, he saw him with a bottle containing liquid and a lighter that he was continually sparking.

• He engaged with Mr Molayee in conversation in another language.

• There was a strong smell of fumes coming from inside the vehicle.

• When Mr Molayee set himself on fire, he tried to open the rear door to render assistance but it was locked.

• Mr Molayee, who was fully engulfed in flames, opened the front door suddenly, causing SC Chand to stumble backwards. He felt Mr Molayee was trying to get to him.

Autopsy results

83. Forensic Pathologists, Dr Li Ma and Dr Beng Ong performed an external and full internal post-mortem examination on 14 May 2021.69 The relevant BWC footage of the incident was provided to them.

84. The post-mortem examination revealed extensive partial thickness burns involving around 78% of the body surface area. While three wound tracks were identified from projectiles, only two were retrieved during the examination, with one entering the right upper arm and the right mid back. The gunshot wounds showed features found to be consistent with distant range gunshot wounds.

85. A post-mortem CT scan demonstrated an air embolism in the right heart, pulmonary trunk, and its major branches, supportive of embolisation of the projectile located in the left pulmonary artery. Minimal intraabdominal haemorrhage was associated with laceration of the liver, suggesting death was likely rapid and was supportive of acute circulatory collapse.

86. Toxicology testing conducted on post-mortem blood, urine and vitreous samples detected methylamphetamine at a nontoxic level in the blood and urine; amphetamine at a nontoxic level, Buprenorphine (an opioid used to treat opioid disorder) at nontoxic levels in the blood and urine, and codeine.

67 Ex B23, [15] 68 Ex B23, [20] onwards 69 Ex A4 Inquest into the death of Omid Molayee Page 11 of 30

87. Post-mortem examination showed life threatening injuries to the chest secondary to the gunshot wounds. The mechanism of death was respiratory and circulatory collapse. In addition, it was noted that life threatening injuries to the chest secondary to the gunshot wounds were also sustained to 78% of the body surface. Such injuries could rapidly cause shock and make the deceased more susceptible to the fatal effects of the gunshot wounds sustained. As such, the thermal injuries were considered a significant contributory factor to the cause of death.

88. The cause of death was found to be gunshot wound to the chest, with other significant conditions listed as thermal injuries.

Investigation findings

89. Police from the Internal Investigation Unit, Ethical Standards Command (ESC) attended the incident location where the scene was processed, and an extensive forensic and ballistics examination was carried out.

90. A forensic examination of both crime scenes, namely the car park and Ms Pooyan’s residence, was conducted, including the weapons of the officers involved.70 Photographs of the scenes as well as Mr Molayee deceased in the back of the ambulance were sourced. Forensic testing of Mr Molayee’s clothing confirmed petrol residue was present.71 While processing the residence, it was noted by forensic officers that there was a strong smell of petrol detected in the bedroom, but there were no obvious signs of staining to the carpet or bedding.72

91. Extensive interviews, statements, exhibits, and records were obtained as part of the coronial investigation and included in the inquest brief. A detailed coronial report was provided on 15 November 2021.73 An audio copy of the radio transmissions and CAD recordings were referred to in the coronial report.

92. The records obtained indicated Mr Molayee had not sought any recent intervention for depression or anxiety. Nor had he previously indicated any intent to self-harm or that he was suffering from suicidal ideation.

Police Training - Operational Skills Assessment of response

93. Following Mr Molayee’s death, Detective Sergeant Downey asked A/Snr Sergeant Werth, the Officer in Charge of the Business Operations Unit (formerly the Operational Skills Section) to conduct a review of the circumstances surrounding the death and whether the actions taken in response were consistent with QPS Policy, procedures, and training.74

94. After considering the requirements of the Situational Use of Force Model in the QPS Operational Procedures Manual (OPM) 14.3.2, which are to be satisfied for an application of force to be regarded as appropriate, A/Snr Sergeant Werth considered the lethal use of force by SC Collander was justified.

70 ExC1, C2, C3 & C4; Log Ex C7 & C8 71 Ex C4, pg. 3 72 Ex A5, pg. 12 73 Ex A5 74 Ex B25 Inquest into the death of Omid Molayee Page 12 of 30

95. A/Snr Sergeant Werth noted that there were two main threats presented by Mr Molayee. The first was his vehicle. The second was the fuel ignition source he was threatening to use within his vehicle.75

96. SC Chand and Constable Sandhu mitigated the threat posed by the vehicle when they barricaded it by parking the police vehicle in front of the Holden Astra.76 This barricade was broken after Mr Molayee opened the front door once alight and exited the vehicle.

97. A/Snr Sergeant Werth formed the view that Mr Molayee’s conduct in moving towards officers who were withdrawing, particularly SC Chand, while engulfed in flames ‘may be perceived as a type of last-ditch effort to rouse a suicide by police reaction’.77

98. In terms of the actions of police in the lead up to the shooting, A/Snr Sergeant Werth noted the following:78

• After locating Mr Molayee’s vehicle, Constable Sandhu and SC Chand sought urgent assistance.

• SC Chand commenced verbal communication with Mr Molayee to establish rapport and deescalate the situation. SC Chand also directed Constable Sandhu to tell attending units to deactivate their lights and sirens to deescalate the situation.

• SC Chand was communicating with Mr Molayee for around 3-4 minutes when the two PSRT units arrived at the scene.

• Constable Sandhu did not have any substantial involvement with the incident and was standing just behind SC Chand, who was communicating with Mr Molayee.79 After Mr Molayee collapsed after being shot, Constable Sandhu assisted by retrieving a fire extinguisher and deploying it. A/Snr Sergeant Werth was of the view that his actions were appropriate during the course of the incident given the circumstances.80

• SC Chand was attempting to utilise tactical communication strategies with Mr Molayee prior to the arrival of PSRT, in an attempt to buy time and get him to change his mind. He was captured on BWC footage to say, ‘don’t do that. Just talk to me’ when Mr Molayee raised a 2 litre bottle containing a yellow liquid while looking at the PSRT officers.

• SC Chand’s attempts to communicate with Mr Molayee were intended to achieve a positive and safe outcome in a highly unpredictable situation, which needed to be deescalated.81 His use of the baton in an attempt to break the window was intended to stop Mr Molayee from killing himself by fire and was justified.

• The BWC footage showed Mr Molayee appeared to pursue SC Chand while on fire. SC Chand’s decision to run and tactically reposition himself to a safe location contributed to the decision by other police to use lethal force.82 75 Ex B25, [30] 76 Ex B25, [32] 77 Ex B25, [35] 78 Ex B25, [50] onwards 79 Ex B25, [58] 80 Ex B25, [61] 81 Ex B25, [72] onwards 82 Ex B25, [75] Inquest into the death of Omid Molayee Page 13 of 30

• Having considered the situational use of force model requirements as outlined in Chapter 14.3.2 of the OPM, in particular the continual threat assessments to be conducted, A/Snr Sergeant Werth was of the view that the assessment conducted as to the threat presented to SC Collander accorded with established QPS policy, training and doctrine.83

• The use of the less lethal multi launchers was justified in the circumstances.84 Any attempt by the officers to deploy less lethal use of force options, such as a baton or open hand tactics would have been inappropriate and tactically unsound, placing the officers in extreme risk of death or serious injury.85

• SC Collander’s actions in shooting Mr Molayee to stop the threat accorded with training.86

• There was a significant risk to all officers in attendance catching fire or being burnt had there been contact with Mr Molayee.87 While Mr Molayee was not armed, he was a risk while he was on fire, and appeared to be running at police with his arms outstretched.

• SC Collander called on Mr Molayee to get on the ground at least three times before discharging his firearm. SC Collander could justify his decision to deploy lethal force as it was in response to an honestly perceived imminent and legitimate threat to the life of the other officers in attendance, which was capable of being inflicted by Mr Molayee.88

• The decision to use lethal force was reasonable, proportionate, and appropriate in the circumstances.89 Furthermore, it was legally defensible90 as well as tactically sound and effective.91

• Other use of force options available to police, such as tactical repositioning and situational containment options were unviable once Mr Molayee was alight given the proximity of the incident to members of the public and the extreme risk this posed.

83 Ex B25, [121] 84 Ex B25, [155] 85 Ex B25, [152] 86 Ex B25, [181] 87 Ex B25, [184] 88 Ex B25, [195] 89 Ex B25, [196] 90 Ex B25, [197] 91 Ex B25, [198] Inquest into the death of Omid Molayee Page 14 of 30

99. A/Snr Sergeant Werth said that Police may have caused the initial escalation of the incident after SC Chand and Constable Sandhu found Mr Molayee.92 Mr Molayee may have set himself alight due to the sudden appearance of police uniforms around his vehicle. While both officers were in the process of trying to negotiate with Mr Molayee, this communication had not proceeded enough to effect any meaningful behavioural change. The surrounding of Mr Molayee’s vehicle by PSRT officers was not required given his vehicle was already contained.

100. A/Snr Sergeant Werth outlined the police firefighting equipment and training provided, noting that most police vehicles have at least one fire extinguisher.93 The extinguisher used on this occasion appears to have been the right type and the tactical discussion as to the use of the extinguisher by SC Holt and Manson, and SC Sheppard and Cheung-Fook was the correct tactical decision.94 Basic firefighting training only is administered by an external provider to police and is aimed at the workplace rather than scenarios such as Mr Molayee’s.95

101. A/Snr Sergeant Werth made a number of recommendations after reviewing this incident:96 I. Training of police recruits and in service officers on self-immolation should include basic fire-fighting skills and the use of fire extinguishers.

II. More robust and continuous training of police recruits and in service officers on tactical repositioning options with a focus on –

(a) preventing escalation of incidents by creating space within the incident area.

(b) providing a means of escape for police to tactically reposition in order to reduce the immediacy of lethal force usage.

(c) Ensuring the safety of all in attendance by reducing potential victims at the incident to a minimum.

III. More robust and continuous training of police recruits and in service officers on incident management procedures.

102. A/Snr Sergeant Werth noted that after this incident, an Online Learning Product was developed to educate officers on the threat of self-immolation.97

103. Specific scenario-based training has been developed for all police, including the planning of the approach to tactically dangerous situations and tactical repositioning and de-escalation options with members of the public threatening to self-immolate.98 92 Ex B25, [201] 93 Ex B25, [203] 94 Ex B25, [203] 95 Ex B25, [204] 96 Ex B25, [213] on wards 97 Ex B25, [221] 98 Ex B25, [222] Inquest into the death of Omid Molayee Page 15 of 30

104. Further information was provided in response to the recommendations made by A/Snr Sergeant Werth by Senior Sergeant Bailey, the Training Operations Coordinator, Operational Training Services.99 Snr Sergeant Bailey noted100 that on 29 March 2021, an Online Learning Product (OLP) was released on the ‘Use of Accelerants and SelfImmolation’.

105. The intention is to better prepare police to respond to incidents where there is a threatened or actual use of accelerants. The product encourages officers to think ahead and make informed decisions to better protect the community. It covers topics such as decision making, situational use of force model, Behavioural Influence Stairway Model, custody, arrest risk evaluation and psychological first aid.101

106. While there is no formal face to face training as to the use of fire extinguishers and fire blankets by police, Snr Sergeant Bailey considered an additional chapter could be added to the OLP on both the use of the fire extinguisher and blankets.102

107. With respect to the second recommendation made about tactical repositioning training, Senior Sergeant Bailey noted103 that Police recruits are provided with lessons on tactical repositioning as part of the Firearms training component and are continuously taught about tactical repositioning in both policing skills and Taser training.

108. As of 1 July 2022, in service officers commenced scenario training as part of their yearly requalification. These scenarios involve tactical repositioning in Dynamic Interactive Scenario Training. Senior Sergeant Bailey supported the recommendations made by A/Snr Sergeant Werth and was of the view that the current OLP can be improved to include information and demonstrations on the use of both fire extinguishers and blankets.104

109. Supplementing Senior Sergeant Bailey’s response was a further statement from Sergeant Gordon Reynolds, Frontline Skills and Training Officer at the Operational Capability Centre.105 He reiterated the need for additional modifications to be made to the current OLP having had personal experience with a petrol fire where he suffered burns to 25% of his body. He suggested the QPS consider the use of fire blankets as a suitable additional resource provided to officers in responding to such an incident, as well as the possible use of a simulator to allow for scenario-based training in responding to fires.106 Critical Incident Analysis

110. On 10 February 2021, the Internal Investigations Group, ESC asked that an internal Critical Incident Analysis be undertaken of the initial police response to the events leading to Mr Molayee’s death.107 An analysis was conducted based on the information provided and timeline of police actions undertaken during the initial police response, up to the time Mr Molayee self-immolated.

99 Ex B25.1 100 Ex B25.1, [13] onwards 101 Ex B25.1, [16] 102 Ex B25.1, [19] 103 Ex B25.1, [20] 104 Ex B25.1, [28] 105 Ex B25.2 106 Ex B25.2, [15] – [19] 107 Ex C25 Inquest into the death of Omid Molayee Page 16 of 30

111. A report was subsequently prepared by A/Inspector Timothy Mowle for the purpose of identifying immediate lessons and expediting changes to procedures and practice where necessary.108 His conclusions were as follows:

• Once Mr Molayee was located in the carpark, having considered the footage obtained via dashcam and BWC, it was noted that SC Chand had established a negotiation platform and was attempting to communicate with him.109 This was taking place when the officers from ZE791 were being positioned at the front offside of the vehicle and officers from ZE790 were approaching from the rear of the vehicle on foot.

• There were three police vehicles and six uniformed police officers in close proximity and visible to Mr Molayee. Dashcam footage from ZE791 showed Mr Molayee actively scanning his surroundings, and his attention was drawn away from SC Chand a number of times, who was attempting to negotiate with him.110

• When SC Shepherd entered the frame, Mr Molayee can be seen leaning over in his seat and pouring the contents of the container over his head.111 As SC Chand struck the window, Mr Molayee ignited the accelerant and the driver’s compartment was engulfed in flames.

108 Ex C25, pg. 4 109 Ex C25, pg. 9 110 Ex C25, pg. 10, Figure 4 111 Ex C25, pg. 10 Inquest into the death of Omid Molayee Page 17 of 30

• At 22:02:04, Mr Molayee exited his vehicle while engulfed in flames and ran in the direction of the officers positioned to the left of ZE790. SC Chand and SC Manson made distance and repositioned. SC Holt gave verbal commands that he ‘get back, get back’ after which a non-lethal round was fired.112 The same command was issued before a further four non-lethal rounds were fired. SC Shepherd also fired one less than lethal round.

• At 22:03:13, Mr Molayee was moving toward the front of ZE790 and SC Shepherd moved back to create distance. SC Cheung-Fook, holding a Perspex shield moved forward, within two metres of Mr Molayee. SC Collander drew his firearm and fired four rounds.113

• From the time crew SC402 located Mr Molayee to when the lethal shots were fired was approximately 6 minutes and 20 seconds.114

112. In terms of communication, namely radio, tactical and verbal, the following were noted by Acting inspector Mowle:

• While holdings as to Mr Molayee’s Mental Health were not available, the responding crews had sufficient information given the known circumstances to determine the nature of the task and plan accordingly. This is reflected in the immediate response of SC402, who established a negotiation platform, providing ample space and distance with Mr Molayee, using non-threatening body language and gestures during the interaction, and asking that crews not use lights and sirens when approaching.115

• While the timely response of all crews is admirable, it was noted that there was a lack of radio communication between the first response and subsequent crews (PSRT and SC441).116

• Command deficiencies were observed during the analysis, particularly within the team dynamics displayed by ZE790 and ZE791, which negatively impacted the outcome:117

• At no time was SC Chand recognised as the on-ground commander.

• One team leader did not assume control of ZE790 and ZE791 – they acted as two small independent teams.

• While discussion was had between the team leaders for ZE790 and ZE791, SC Chand was not included in the conversation, decision making or subsequent actions.

• The initiation call when responding to Mr Molayee igniting the accelerant was not the team leader of ZE790, rather SC Manson. The situation quickly declined with numerous officers yelling instructions and no obvious person being in command and control.

112 Ex C25, pg. 12 113 Ex C25, pg. 12 114 Ex C25, pg. 12 115 Ex C25, pg. 14 116 Ex C25, pg. 14 117 Ex C25, pg. 14 & 15 Inquest into the death of Omid Molayee Page 18 of 30

• SC Chand, as part of the first response unit and most senior officer present at the time was the on-ground commander. He had the most situational awareness and appeared to have the situation under control.118 As such, the secondary units arriving on the scene had the responsibility to make contact with him and receive a situational briefing and discuss taskings. However, this did not occur.

113. In terms of management, the following observations were noted:119

• The actions of SC402 were commendable as a first response unit and reflected a sound approach to the situation based on the information and their situational awareness once they located Mr Molayee.

• After the arrival of ZE790 and ZE791 there was an observable change in Mr Molayee’s behaviour. There was considerable activity by these officers around the subject vehicle. He can be seen to look in the direction of these officers as equipment is unpacked and appears agitated.120

• The positioning of ZE791 to the front left side of the vehicle was done to provide vehicle mitigation capability, but the decision was made without consultation with SC Chand or a deeper appreciation of the situation. The same was the case with the decision to place ZE790 to the rear of Mr Molayee’s vehicle.

• A more prudent approach for ZE790 and ZE791 would have been to stage in close proximity, but out of sight from Mr Molayee.121

114. In terms of contributing factors, it was acknowledged by A/Inspector Mowle that there was no known mental health condition or treatment and no flags to this effect on QPrime. However, there was an observed change in Mr Molayee’s behaviour upon the arrival of multiple police units.

115. A/Inspector Mowle acknowledged it remained unknown whether the self-immolation actions of Mr Molayee were a consequence of the arrival of the additional police units or that was always his intended course of action.122

116. The following two findings were made by the Review:123 a. Review Finding 1 (Communication): Numerous command deficiencies, linked to verbal and tactical communications, were observed during this analysis. At no time, was it was apparent that the team leader for either of the PSRT teams, ZE790 or ZE791, recognised SC Chand as the on-ground Commander. One of the leaders did not assume overall control for the teams. There was no evidence that either team had involved SC Chand in any conversation, decision making or subsequent actions. There was evidence of deficiencies in leadership and team discipline within ZE790 and ZE791.

118 Ex C25, pg. 15 119 Ex C25, pg. 15 120 Ex C25, pg. 15 & 16 121 Ex C25, pg. 16 122 Ex C25, pg. 17 123 Ex C25, pg. 17 & 18 Inquest into the death of Omid Molayee Page 19 of 30

It was recommended that the Senior Leadership Team, Specialist Services Group, in consultation with ESC review the BWC footage and walkthrough interview recordings of their members involved in this incident with a view to self-identifying lessons regarding team leadership, team discipline and team dynamics and report the outcomes back to ESC and Assistant Commissioner Condon.124 b. Review Finding 2 (Management): Upon arrival of the PSRT teams there was an observed change in Mr Molayee’s behaviour. While it was accepted that the intentions and initial positioning of ZE790 and ZE791 were noble, this occurred without consultation with SC Chand and seemingly in contravention of the warnings broadcast and the sitrep provided by SC Chand. The PSRT teams could have achieved the same objectives in a more tactically sound manner.

It was recommended that PSRT review the adequacy of their Standard Operating Procedures regarding initial interaction with the on-ground commander upon arrival at an incident location.

Response to Critical Incident Analysis

117. Following the completion of the Critical Incident Analysis, A/Superintendent Partrige provided a response on behalf of the Specialist Response Group to the conclusions drawn and recommendations made.125

118. A/Superintendent Partrige relevantly noted:

• PSRT’s primary role is public order policing, and the critical incident response capability of such a team is not commensurate to Police Tactical Groups.126

• The threat posed by Mr Molayee to the general public, while having threatened self-harm, was considerable.

• Review finding 1 (communications):

• Considering the significant threat posed by Mr Molayee, the responding police units’ priority upon his location was to isolate and contain the threat by providing backup to the sole first responding unit.127 It is ‘common’ and tactically sound for units to respond with haste to dangerous situations where there may be a threat to a fellow officer’s safety.

• When PSRT arrived, SC Chand was preoccupied in negotiating with Mr Molayee. As such, demands for information or direction from responding police units could have had the potential to detract from his ability to effectively perform his duties. The responding PSRT priority, to get to the incident location, obtain situational awareness and provide assistance to their colleague and contain the threat was understandable, desirable and tactically appropriate.128 124 Now retired 125 Ex C26 126 Ex C26, pg. 1 127 Ex C26, pg. 2 128 Ex C26, pg. 3 Inquest into the death of Omid Molayee Page 20 of 30

• There was some contradiction in the suggestion SC Chand was considered the on-ground commander, and at the same time criticise the lack of a single PSRT team leader.

• The speed of events, initiated by Mr Molayee upon PSRT arrival, prevented consultation between officers and the establishment of a command framework.129

• It was acknowledged that the command structure of the responding PSRT units in this incident was not clear. To rectify this issue, instructions have been amended to clearly identify the senior PSRT officer in situations where officers of superior rank are not in attendance.130

• A/Superintendent Partrige did not support the finding that PSRT officers initiated the emergency action when Mr Molayee self-immolated. Footage showed such actions being taken by SC Chand when he attempted to smash the driver’s side window.131 Further, he disagreed with the finding that the reaction of these officers to a rapidly escalating situation was indicative of poor team discipline or a lack of leadership either in PSRT or by SC Chand.

• With more time, the responding officers should have been able to better position their resources and plan their contingency responses. However, the actions of Mr Molayee did not afford them this opportunity.132

• Review finding 2 (management):133

• The attendance of responding PSRT officers appeared to influence the behaviour of Mr Molayee. However, whether this was in fact the case will never be known. The primary responsibility was to isolate and contain the threat.

• The general duties vehicle parked in front of Mr Molayee vehicle had not achieved containment. There was sufficient room around the vehicle (approximately 1.5 metres in front and behind) that may have allowed Mr Molayee sufficient space to manoeuvre his vehicle to ram his way free.

• Considering his actions leading up to the incident, and his clear deteriorating mental state and desire of avoid police, it was reasonable for responding police to conclude Mr Molayee was highly motivated to avoid arrest or detention by police.134

• Effective containment of offenders in vehicles requires responding officers to cordon the subject vehicle tightly with police vehicles or other objects to prevent escape. Considering the threat posed by Mr Molayee, the PSRT officers had no other choice but to position their vehicle as they did to achieve effective containment. This was tactically sound.135 129 Ex C26, pg. 3 130 Ex C26, pg. 3 131 Ex C26, pg. 3 & 4 132 Ex C26, pg. 4 133 Ex C26, pg. 4 onwards 134 Ex C26, pg. 5 135 Ex C26, pg. 5 Inquest into the death of Omid Molayee Page 21 of 30

• The positioning of the PSRT vehicles was consistent with the training provided to PSRT officers about vehicle interception strategies.

• A/Superintendent Partrige shared the conclusions reached as to the commendable actions taken by SC402 in responding to Mr Molayee but questioned why there was a distinction made with the PSRT officers who subsequently attended.136

• The sitrep provided by SC Chand for responding crews not to have lights and sirens did not include a request for vehicles to stay away or stage elsewhere, and as such, the positioning of the PSRT vehicles was not in contravention of such a sitrep.137

119. A/Superintendent Partrige was of the view that the unfortunate outcome of the incident on 6 April 2020 was entirely due to the actions of Mr Molayee. The officers in attendance prioritised public safety over competing safety considerations, including their own safety.138 He was of the view that the actions of all officers were in accordance with their training and current policy, and were tactically sound and effective.

Subsequent QPS response to Critical Incident Analysis and Response by A/Superintendent Partrige

120. On 22 October 2021, following the response provided by A/Superintendent Partrige to the Critical Incident Analysis, the Critical Incident Review Sub-Committee (CIRS) met to discuss the matter.139 The recommendations made by A/Inspector Mowle were noted.

121. The CIRS formed the view that there were organisational learnings to be had from the incident, which will ensure continual improvement across the organisation. It was recommended that an Operational Advisory Note (OAN) be prepared and distributed state-wide. The intent of the OAN was to remind officers of:140

• Command and control.

• Situational awareness.

• Ongoing appreciation – including the actions of the subject member and the potential consequences of police tactical action; and

• De-escalation strategies.

122. The OAN was approved for state-wide distribution by the former Chair of the CIRS, Assistant Commissioner Condon141 and was circulated on 5 November 2021.142 It requires that officers follow three steps when responding to a significant event:

• Gaining situational awareness in tactically dangerous situations.

136 Ex C26, pg. 6 137 Ex C26, pg. 6 138 Ex C26, pg. 6 139 Ex A5, pg. 91; Ex C28, pg. 2 140 Ex A5, pg. 91 141 Ex A5, pg. 92 142 Ex A5, pg. 96; Ex 28.2; Ex C28, pg. 3 Inquest into the death of Omid Molayee Page 22 of 30

• Ongoing appreciation when considering police tactical action.

• Policing with influence and its impact on de-escalation techniques.

123. The recommendations made by A/Inspector Mowle have since been considered and actioned where appropriate. The following status update was provided by A/Senior Sergeant Anthony Bradbury, Operational Review Unit, ESC:143 Recommendation 1: On 17 August 2021, A/Superintendent Partrige met ESC investigators and reviewed the BWC and segments of the walkthroughs with the officers involved, with a view to self-identifying lessons regarding team leadership, team discipline and team dynamics. The response provided by A/Superintendent Partrige in response to the Critical Incident Review was supported by the Assistant Commissioner, Operations Support Command.144 Recommendation 2: It was acknowledged by A/Superintendent Partrige that the command structure of the responding PSRT was not clear during the incident. This was rectified by PSRT instruction 30/2021, Command Delegation and Daily Taskings Instructions, which clearly identified the senior PSRT officer in situations where officers of superior rank are not in attendance.145 This requires the nomination of a single Team Leader when responding to an incident where two teams are responding.146 Conclusions on Inquest Issues Findings required by s. 45 of the Coroners Act

124. I am required to find, as far as possible, the medical cause of the death, who the deceased person was and when, where and how he came by his death. As a result of considering all the evidence, including the material contained in the exhibits, I make the following findings: Identity of the deceased – Omid Molayee How he died – Mr Molayee entered Australia illegally from Iran in 2011. He became an Australian citizen after being granted a Protection Visa. He had been living with his partner and her children at Sunnybank for several months. After dousing his partner and himself with fuel, he threatened to set her alight and himself. After she was able to escape, he left the residence in his car and parked in a restaurant carpark at Sunnybank.

He threatened to set himself and Police Officers on fire.

143 Ex C28, 144 Ex C28, pg. 2 145 Ex C28, pg. 3 146 Ex C28.1 Inquest into the death of Omid Molayee Page 23 of 30

Police arrived and attempted to negotiate with Mr Molayee while he remained seated in his car.

After more police arrived, he poured fuel over his body and set himself alight. He then exited the vehicle and ran at police before being shot by a police officer at the scene.

Place of death – Corner McCullough Street and Mains Road

SUNNYBANK QLD 4109 AUSTRALIA Date of death– 6 April 2020 Cause of death – Gunshot wounds to the chest, with other significant conditions noted as thermal injuries.

The appropriateness and sufficiency of the actions by the attending police officers on 6 April 2020 in relation to Mr Molayee, including but not limited to, the tactical strategy employed, effectiveness of the negotiations conducted and the decision by police to use lethal force.

Whether the police officers involved acted in accordance with the Queensland Police Service (QPS) policies and procedures then in force and whether said actions were appropriate.

125. A primary consideration of the inquest was the actions of the police in responding to this incident, which culminated in the use of lethal force. In this respect I have had regard to the evidence of the relevant internal QPS experts called to give evidence.

126. The initial viewing of the confronting video images of Mr Molayee running at police in the McDonald’s carpark raised concerns about whether the actions of the police were appropriate, as it appeared unclear what harm a “man on fire” might cause the officers.

127. However, I was ultimately satisfied that the actions of each of the officers who attended the incident were appropriate and complied with the relevant QPS policies and procedures. Efforts were made to cordon and contain Mr Molayee and to limit the risk of harm and threat presented by him. This was accepted by Mr Molayee’s family, the Commissioner and the involved officers.

128. In particular, SC Chand should be commended for his efforts to calmly communicate with Mr Molayee and build rapport with him in an effort to de-escalate the situation. It is possible but by no means certain that had SC Chand been given the opportunity to continue his engagement with Mr Molayee the outcome may have been different.

129. Mr Molayee’s actions were ultimately consistent with his stated intent from earlier that night at 9:13pm, and then at 9:45pm, when he said: ‘if they try anything, I am going to set myself and the Police Officers on fire’

130. Other emergency services were also called to assist. However, the incident escalated before they were in a position to do so.

131. In terms of the positioning of the PSRT vehicle ZE791, I agree that that the presence of SC Chand and Constable Sandhu’s iLoad van in front of Mr Molayee’s Holden Astra Inquest into the death of Omid Molayee Page 24 of 30

was not sufficient to effectively contain and isolate the threat he posed should he manage to exit the carpark in his vehicle.

132. There were avenues for him to drive away and the risk was high if he became a “mobile stronghold”. I accept that the priority to protect the public by keeping Mr Molayee’s vehicle in that location outweighed considerations relating to the possibility of escalating an already volatile and high-risk situation. This was the evidence of each of the officers who made the tactical decisions, and was supported by Superintendent Partrige.

133. While Inspector Mowle conceded that placement of the PSRT vehicle within the carpark was necessary, he considered this could have been effected in a covert fashion. However, such a conclusion does not detract from the soundness of the tactical decision made by the officers in ZE791 to position the vehicle as they did, given the urgency of the response required, what was communicated to the officers before attending that evening, and the public location of Mr Molayee’s vehicle.

134. The command deficiencies within PSRT identified by Inspector Mowle in the Critical Incident Analysis have to be considered in the context of the caveat he placed his review. He agreed that it was done with the benefit of hindsight and was designed to establish what he perceived to be best practice in order to provide learnings for improved operational practices.

135. While conceding that the actions of the PSRT officers were tactically sound and accorded with training, policy, and procedure, Inspector Mowle made several suggestions about how such a response could have been improved, including engagement with the scene commander and the positioning of the vehicles.

136. The subsequent response of Superintendent Partrige identified the practicalities of the analysis in the context of the threat posed, as well as the changes that have since been made to the Instruction issued to PSRT with respect to the nomination of a single team leader across the PSRT teams, and the robust training provided regularly to all officers in PSRT.

137. Superintendent Partrige noted that with time, the responding officers would have been able to better position their resources and plan their contingency responses. However, the actions of Mr Molayee did not afford them such opportunity.

138. In terms of the use of force options utilised by the officers, including the less than lethal 40mm launchers, I accept the evidence of S/Sgt Werth that such measures were necessary and justified in the circumstances in an attempt to mitigate the risk and threat posed by Mr Molayee. I also agree that the use of open hand tactics or batons would have been inappropriate and tactically unsound, placing the officers at risk of death or serious injury.

139. S/Sgt Werth’s opinion was that the decision to use lethal force by SC Collander was justified, reasonable, proportionate, and appropriate in the circumstances to stop the threat posed by Mr Molayee.

140. There was no other use of force option available to adequately stop the imminent risk of serious injury or death presented by Mr Molayee. I accept that conclusion. It is clear from SC Collander’s evidence that this was not a decision he made lightly. It has affected him greatly.

Inquest into the death of Omid Molayee Page 25 of 30

141. I heard from each of the attending officers. Each said that during this incident they were genuinely in fear for their life. The incident has clearly affected all the officers who attended, and none had responded to an incident of this nature before. The event was rapid and escalated quickly. The time from when Mr Molayee was located and the lethal shots being fired was approximately 6 minutes and 20 seconds

142. Ultimately, I agree that the unfortunate outcome of the incident on 6 April 2020 was due to the actions of Mr Molayee. I accept that the officers in attendance prioritised public safety over competing safety considerations, including their own safety, in order to address the threat posed, which was appropriate in the circumstances.

143. Submissions for the involved officers highlighted the differing views of the QPS witnesses in relation to the placement of the PSRT vehicle within the carpark and what is the best practice in relation to the containment of vehicles, particularly whether close containment of vehicles was preferable.

144. I accept that SC Chand was in command of the incident initially, but that PSRT had allocated specific roles in terms of who should breach the vehicle, use of the fire extinguisher and non-lethal force, while SC Chand continued to negotiate with Mr Molayee. I agree that the events unfolded too quickly for any formal command structure to be established.

Whether the training provided to officers in responding to a similar incident is sufficient.

145. S/Sgt Werth made a number of recommendations relating to training following this incident. Most of those have been implemented by the QPS.

146. More robust and continuous training of police recruits and officers on tactical repositioning options has been provided and included in various training activities, including those mandated for yearly requalification in policing skills generally, as well as the use of firearms and Tasers.

147. With respect to training on responding to self-immolation and accelerants, an online learning product was introduced in March 2021, which is now mandatory for all officers.

This includes a section on the use and deployment of fire extinguishers and their location within police vehicles.

148. To reflect the organisational learnings from this incident, an Operational Advisory Note was also distributed on 5 November 2021, which reminded officers about command and control, situational awareness, ongoing appreciation, and tactical action, as well as de-escalation strategies.

149. With respect to the resources that may have assisted the officers in responding to a similar incident, the availability of a fire blanket was suggested. While noting that such a resource may not be able to be readily added to the accoutrements carried by police officers, Counsel Assisting submitted that I could recommend that the QPS consider whether fitting vehicles with a fire blanket would be feasible to assist in situations where officers are required to respond to threats to self-immolation incidents.

Inquest into the death of Omid Molayee Page 26 of 30

150. Counsel Assisting also submitted that consideration could also be given to the QPS fitting specialist unit vehicles, such as PSRT or SERT vehicles, with a larger fire extinguisher, and whether this would assist officers to respond to an incident of this nature.

151. I note that these issues were also considered in the April 2023 findings of the Inquest in relation to the death of William Grimes. There the Commissioner submitted there was no evidence that a fire blanket kitted in a service vehicle would have assisted in the incident or altered the outcome.

152. As in the Grimes inquest, I agree that in the circumstances of Mr Molayee’s death it is not clear that a fire blanket could have been safely deployed by the officers in circumstances involving an accelerant which resulted in intense heat and a man running around a carpark while on fire. A fire blanket may not have provided any assistance in this situation.

153. Similarly, I accept that the provision of fire extinguishers in service vehicles is primarily for the containment of fire and the use of a dry chemical fire extinguisher on a person is a last resort as propellant and gases may be harmful. However, this ought to be weighed against the fact the person may be on fire and has at that time suffered severe injuries if completely alight. As was noted by the expert evidence of Inspector Mallouk in the Grimes inquest, fire-extinguishers “have an asphyxiant effect but it’s better than no option at all.”

154. Mr Molayee’s family expressed concern about the reactive nature of QPS training, and the fact there had not been any specific training of the PSRT Team in relation to a scenario of a similar nature. It was submitted that deaths involving accelerants, including self-immolation, are increasing in frequency, and where the PSRT are used as a “force multiplier” in crisis situations, and where a firearm has been deployed, focused training should be provided in relation to such a scenario. It was submitted that I should recommend: ‘A more contemporaneous review of situational training should take place after a police officer has used deadly force, based on the Critical Incident Review.’

155. The importance of incorporating lesson from prior incidents was recognised in the 2017 police shootings inquest,147 where it was recommended in recommendation 7: Operational skills and tactics training continue to incorporate 'lessons learned' from previous shootings into scenario based training, including anticipating the presence of weapons on arrival at the scene, tactical withdrawal, and managing bystanders during an incident.

156. The Commissioner submitted that the training issues identified by the family were already addressed in scenario based training. This is based on reviews such as Critical Incident Reports. It was also submitted that it would be difficult to provide a specific scenario to reflect the events associated with Mr Molayee’s death (self-immolation) and that the QPS had already developed a relevant online learning product. I accept that submission.

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The adequacy of the investigation into the death conducted by officers from the Queensland Police Service (QPS) Ethical Standards Command.

157. The investigation conducted by D/Sgt Downey, as detailed comprehensively in the 99 page coronial report, was professional and thoroughly considered the circumstances of this matter.

158. All of the relevant exhibits were obtained, which extended beyond sourcing material relevant to considering the s 45 findings, but assisted in determining whether further preventative recommendations could be made.

159. With respect to concerns about officers being left to wait in the rain prior to ESC officers attending, Officer Downey identified several contradictory and inconsistent provisions within the Operational Procedures Manual and Internal Investigations Group Command Instructions. Those related to the separation of officers, whether officers need to stay at scenes and welfare support following an incident. This resulted in amendments supporting officer welfare, including their removal from the scene of the incident as soon as reasonably practicable.148

160. The Commissioner’s submission acknowledged that this would be rectified.

Comments and recommendations

161. Mr Gnech submitted that police welfare should remain “front and centre” and the protection and welfare of emergency services workers should not be understated. He noted the 2017 inquest recommendations relating to police shootings concluded there were limited processes to deal with the welfare of officers.149

162. Recommendation 10 from the 2017 police shootings inquest was: Officers involved in a critical incident involving a fatality be mandated to attend at least one session with a psychologist or psychiatrist independent of the Queensland Police Service (QPS) and that this issue be the subject of a separate review by the QPS. The review should consider:

• the most effective ways of supporting police officers after a critical incident involving a fatality in the medium to long term

• the training of officers in supervisory positions to ensure that they can appropriately monitor officers under their supervision who have been involved in critical incidents involving a fatality; including an awareness of warning signs that an officer is experiencing difficulties; and of steps that can be taken to ensure that such officers receive timely support.

• how appropriate support mechanisms can be established and how the adequacy of existing mechanisms is monitored.

163. Mr Gnech noted that the evidence in this inquest was that the involved officers were experiencing ongoing distress in relation to the impact of the events on them. I accept that submission. He also submitted that the welfare of officers at the scene when they were separated was not dealt with appropriately.

148 Ex B32 149 Recommendations of inquest into the deaths of Anthony William Young; Shaun Basil Kumeroa; Edward Wayne Logan; Laval Donovan Zimmer; and Troy Martin Foster Inquest into the death of Omid Molayee Page 28 of 30

164. Officers were required to remain at the scene for one hour and to sit in locations around the public carpark, exposed to members of the public. For example, Constable Sandhu told the inquest he was required to wait 20m from his police vehicle in the rain and was not offered any immediate support.

165. There were also delays in the forensic testing of officers. It was submitted that no officer took responsibility for the welfare of the involved officers. However, it was accepted that this was not a matter for the ESC investigator but for a senior officer within the District where the incident occurred.

166. Mr Gnech submitted that I should once again recommend that officers involved in critical incidents be mandated to attend at least one session with a psychologist or psychiatrist. He also submitted that for matters of this nature an interim report should be provided to address the impact of the incident on the involved officers, and form part of the evidence at inquest.

167. Mr Gnech submitted that I should recommend that a working group be established to address these issues and that the working group include officers with lived experience of a critical incident, as well as experts in the field of officer well-being.

168. The Commissioner submitted that the separation of officers and ongoing officer welfare was not a matter within the scope of this inquest. It was submitted that there was not enough evidence before the court to conclude that the 8 November 2021 Guidelines for Psychological First Aid (PFA) were not sufficient. Those Guidelines were implemented after the date of this incident.150

169. The PFA Guidelines note that they should be used in the context of providing PFA following a Critical Incident or Potentially Traumatic Event. The PFA Guidelines apply a stepped-care approach, which provides a range of support options to target various levels of mental health intervention.

170. The Commissioner submitted that training in PFA is required for all members, and managers and supervisors are expected to comply with the relevant policies. All officers involved in this incident, apart from the DDO, had completed the relevant training.

171. Following an incident such as this, the OPM requires police forward commanders, regional duty officers and district duty officers to deploy, where possible, a dedicated PFA resource151 to support members. Managers have to provide ongoing monitoring and support in the days and weeks following the exposure. Members are also expected to understand, monitor and take an active role in managing their own mental health.152

172. The PFA Guidelines envisage that support will be provided within 24 hours of an incident, within 2 weeks and then on an ongoing basis. The Guidelines also note that members “may access critical incident leave when they have been directly and immediately involved in a critical incident and where the leave is approved by the appropriate delegate.” 150 Ex C41 151 A peer support officer or trained QPS Chaplain, or in their absence an external trained PFA resource.

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173. The PFA resource is also expected to provide support to the potentially affected members and assist the members to navigate through Ethical Standards Command investigations.

174. Where possible, members involved in a Critical Incident should be removed from the scene at the first available opportunity to cease further exposure to the members and to ensure that the responding dedicated PFA resource is not exposed to the incident as outlined in the OPM.

175. The Commissioner submitted that even if the PSRT officers involved in this incident did not receive sufficient support, any recommendations that the policy should be reviewed would be premature.

176. The PFA Guidelines are due for review on 8 November 2024. It would appear that Mr Gnech’s concerns could be addressed by the following recommendation: I recommend that a serving or retired QPS officer with lived experience of a critical incident in which a person has died is included in any QPS Committee or working group tasked with the review of the Guidelines for Psychological First Aid, together with an external expert on the welfare of police officers.

177. I close the inquest.

Terry Ryan State Coroner

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