Schulte, John

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of John Fredrick Schulte TITLE OF COURT: Coroners Court JURISDICTION: Townsville

FILE NO: 2018/5779 DELIVERED ON: 7 August 2023 DELIVERED AT: Brisbane HEARING DATE(s): 15 June 2022, 22-25 August 2022, submissions to 25 November 2022 FINDINGS OF: Terry Ryan, State Coroner CATCHWORDS: Coroners: inquest, domestic violence, coercive control, risk assessment, firearms, suicide, police response.

REPRESENTATION: Counsel Assisting: Ms C Grant Ms Samantha Schulte: Ms R Berry, instructed by Caxton Legal Service

QPS Officers Warner, Randall Alberich, Molyneux, Palmer, Clark, Matheson, Feltham and D: Ms K McMillan KC, instructed by Gilshenan and Luton Commissioner of Police: Miss E Cooper, instructed by QPS Legal Unit Detective Sergeant Schmidt: Mr S Hollands

Contents Issue 5 – QPS communication with Mrs Schulte on and from 25 December 2018

Introduction

1. John Fredrick Schulte died on the evening of Christmas Day on 25 December 2018 from a single, self-inflicted gunshot wound. He was aged 37 years.

2. Mr Schulte was living at 43 Findlater Street, Oonoonba, at the time of his death.

He had started renting the house a couple of weeks before his death, following a separation from his wife of ten years, Samantha Schulte.

3. Mr Schulte was employed as a labourer on road construction sites with RoadTek, which forms part of the Department of Transport and Main Roads. He was described by colleagues as hardworking and well-liked. His manager told police that in November 2018 he became aware that Mr Schulte was having trouble at home, and Mr Schulte was distressed.1 0F

4. Mr and Mrs Schulte separated on 28 November 2018 after Mr Schulte told Mrs Schulte 'to go and get fucked.'2 This brought to an end a 12 year relationship 1F involving sustained domestic and family violence. Mr and Mrs Schulte shared two sons, who were then aged 4 and 8. The family resided at Julago and Mrs Schulte remained at the family home with their sons after the separation.

5. Mr Schulte’s manager told police that his level of distress increased following the separation. Mr Schulte was often sending text messages to Mrs Schulte and he was advised to get rid of his phone. His work colleagues were reaching out to him at Christmas because they knew he was distressed and did not want him to be alone at this time. However, Mr Schulte had told his colleagues he did not need any help. This was seen as “male bravado” as his colleagues knew he was struggling.3 2F Investigation

6. Mr Schulte’s death was investigated by Detective Sergeant Christy Schmidt of the Queensland Police Service (QPS) Ethical Standards Command (ESC). Broadly speaking, the concerns raised by Mrs Schulte were addressed in the ESC Investigation Report. I agree that Detective Sergeant Schmidt’s investigation was impartial, comprehensive and of a high standard.

7. In the preparation of her report Detective Sergeant Schmidt was assisted by Sergeant Alastair Rhodes, who was Domestic and Family Violence Coordinator in the Moreton District, as well as Acting Sergeant Nicholas Evans, Officer in Charge of the South Brisbane Vulnerable Persons Unit.

8. Detective Sergeant Schmidt found there was evidence to support misconduct allegations against four police officers for failing to ‘adequately investigate apparent risks of domestic and family violence and criminal allegations (rape and threats to kill)’ that were reported by Mrs Schulte to police in the lead up to the death.

1 Exhibit A7, page 90 2 Transcript: 1-6 lines 7-12 3 Exhibit A7, page 90 Findings of the inquest into the death of John Fredrick Schulte page 1 of 26

9. Detective Sergeant Schmidt recommended that three officers receive ‘refresher training’ in relation to investigating domestic and family violence and criminal allegations, including the duties and responsibilities of police.

10. Detective Sergeant Schmidt also recommended that one officer be referred for discipline action for failing to investigate criminal and domestic and family violence allegations in accordance with the Domestic and Family Violence Protection Act 2012, the Criminal Code 1899, and Chapter 9 of the QPS Operational Procedures Manual (OPM).

11. The Domestic and Family Violence Death Review Unit (DFVDRU) conducted a review of the circumstances of the death and police contact with Mr and Mrs Schulte. Mrs Schulte had written to the Coroners Court and requested an inquest into her husband’s death as she had concerns about the adequacy of the police response to her allegations of domestic and family violence in the lead up to the death. Broadly speaking, the most relevant concerns from the DFVDRU review of this matter related to:

• the adequacy of the response by police on 30 November 2018 to Mr Schulte’s threats of self-harm/suicide in the context of domestic and family violence; and

• the adequacy of the response by police to Mrs Schulte’s broader complaints of domestic and family violence on 30 November 2018, 17 December 2018, and 24 December 2018, particularly in the context of Mr Schulte’s known access to firearms.

12. The Coroners Court also engaged the assistance of retired Assistant QPS Commissioner, Clement O’Regan, to review the actions of police in this matter. At the time of giving evidence in this inquest, Mr O’Regan had been retired from the QPS for two years. While Counsel Assisting submitted his evidence was of limited assistance given his retirement, I consider that Mr O’Regan’s evidence on policing techniques and training was relevant to this matter. He was working as the Assistant Commissioner in the Central Region at the time of Mr Schulte’s death.

His policing career spanned some 40 years and included responsibility for police training.

13. Mr O'Regan acknowledged his opinions were based on policing involving the 'WIN' approach ('What's Important Now') rather than the more recent trauma-informed, victim-centric policing of domestic violence which involves a more holistic approach.

Autopsy results

14. An autopsy examination was conducted on 28 December 2018 by Senior Staff Specialist Forensic Pathologist, Dr Botterill. He concluded that Mr Schulte's cause of death was a gunshot wound to the head, consistent with being self-inflicted. No significant additional injuries were identified. There was no natural pathology that might explain Mr Schulte’s deteriorating behaviour in the lead up to his death.

Blood alcohol testing showed a level of 143mg/100ml (0.14 in road traffic terms).

Dr Botterill noted that this level may be associated with behavioural changes that may have impacted on the circumstances leading to the death.

Findings of the inquest into the death of John Fredrick Schulte page 2 of 26

Inquest issues

15. Mr Schulte’s death was reported to the State Coroner as it fell within the definition of a reportable death in the Coroners Act 2003. Reportable deaths include deaths that happen in the course of or as a result of police operations.

Mr Schulte’s death was investigated as a death in police operations because Queensland Police Service officers had gone to Mr Schulte’s home, formed a cordon and attempted to negotiate with him on the night of his death.

16. The role of a coroner is to independently investigate reportable deaths to establish, if possible, the identity of the deceased person, how the person died and what caused the death. The purpose of a coronial investigation is to establish the facts. A coroner is prevented from including in their findings anything that suggests a person may be guilty of an offence or civilly liable.

17. An inquest into Mr Schulte’s death was held from 22 to 25 August 2022. The issues for the inquest were:

18. The findings required by s.45 of the Coroners Act 2003, namely the identity of the deceased person, when, where and how he died and the cause of his death;

19. The appropriateness of the police response to reported concern over the deceased's mental health, domestic violence and possession of weapons made by Mrs Schulte on 30 November 2018;

20. The appropriateness of the police response to reported concern over the deceased's mental health, domestic violence and possession of weapons made by Mrs Schulte on 17 December 2018;

21. The appropriateness of the police response to reported concern over the deceased's mental health, domestic violence and possession of weapons made by Mrs Schulte on 24 December 2018;

22. The timing and adequacy of police communication with Mrs Schulte on 25 and 26 December 2018 and the days following Mr Schulte's death;

23. The appropriateness of the review process of specialist officers such as the Domestic Violence Risk Manager;

24. Whether further specialist training in domestic violence for general duties police and specialist Domestic Violence Risk Managers may prevent future deaths in such circumstances;

25. 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.

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18. It is important to recognise that involvement of the QPS in the events leading up to Mr Schulte’s death took place in late 2018, almost three years before the release of the Women’s Safety and Justice Taskforce, Hear her voice – Report one - Addressing coercive control and domestic and family violence in Queensland.

19. The death occurred almost four years before the November 2022 report of the Commission of Inquiry into Queensland Police Service responses to domestic and family violence – A Call for Change.

20. I accept that the QPS response to the calls for service from Mrs Schulte needs to be considered in the context of the knowledge, information, training and resources regarding domestic and family violence in place in 2018.

21. In that context, the submissions from the Queensland Police Service officers involved in this matter frankly acknowledged there were some failures in the discharge of their duties in accordance with the QPS Operational Procedures Manual. They accepted that some criticism can be made. I agree with the submission from the officers that no individual officer caused the death of Mr Schulte, and no officer acted with malice.

22. As recognised by Counsel Assisting, all of those involved in this matter have experienced trauma and grief, including Mrs Schulte, her sons and her parents, and Mr Schulte’s extended family. I extend my condolences to them.

23. I also acknowledge that the police officers involved in this matter have also experienced personal and professional distress.

24. As recognised by the A Call for Change Report, “policing domestic and family violence is complex, stressful and dangerous”. Officers are expected to make careful assessments but have been overwhelmed by calls for service and been under “pressure to do something quickly, rather than having the confidence to complete it thoroughly”.

The evidence The Background of Domestic Violence

25. Mrs Schulte’s evidence was that her relationship with Mr Schulte involved a long history of domestic and family violence before she made any reports to the police.

She said that Mr Schulte perpetrated domestic and family violence over many years which included emotional, financial, and sexual abuse. She stated that it ‘got very, very bad probably about a year or two before’.

26. However, it appears that almost all of this went unreported to formal services until 30 November 2018, approximately a month before the death. As Mrs Schulte noted in her impact statement, the violence that occurred largely behind closed doors allowed the abusive behaviour to remain invisible, and Mr Schulte was perceived as a “good bloke”.

27. Mr Schulte threatened Mrs Schulte with weapons directly and indirectly. He did so directly by telling Mrs Schulte he was going to shoot her, and indirectly by placing the firearms under the bed where Mrs Schulte slept.

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28. Mr Schulte displayed a high level of sexual jealousy, and became fixated that Mrs Schulte was a lesbian and was having an affair with someone from her work. Mrs Schulte reported that Mr Schulte was ‘very obsessed with sex and pornography’.

29. Mrs Schulte gave evidence of being raped by Mr Schulte. She stated he would sexually assault her. He controlled everything in her life. He constantly phoned and messaged her and would not let her shower alone.

30. By the end of the marriage Mrs Schulte was so fearful of her life that she told her mother: “When he kills me, just get my phone. Because everything is on my phone”.

31. Mr Schulte also threatened that he was going to kill himself and that it would be Mrs Schulte's fault. Mr Schulte had previously attempted suicide before his relationship with Mrs Schulte.

32. Although she was fearful of Mr Schulte, Mrs Schule said she felt ‘unable to leave the relationship’ because it would ‘significantly increase the risk’ towards herself and her children. As a result, she had developed a safety plan which included arranging alternative accommodation for her children and hiding an emergency bag.

Events leading up the death

33. The events leading up to the separation and those which occurred post-separation and up until the death of Mr Schulte involved profound and concerning domestic and family violence of various kinds.

34. Of particular concern was the fact that Mr Schulte was the holder of a weapons licence which authorised him to have registered guns at his home. In circumstances where Mr Schulte had made recent threats to shoot Mrs Schulte and threats to kill himself, his access to guns played a substantial part in the concerns held by Mrs Schulte about her husband’s wellbeing, her own safety and that of her sons.

35. The inquest heard evidence from a psychologist, Ms J, who participated in marriage counselling with Mr and Mrs Schulte in the lead up to their separation and continued her professional affiliation with Mrs Schulte post-separation. Ms J is now deceased.

36. Ms J did not consider that information was required to be shared under part 5 of the Domestic and Family Violence Protection Act 2012 (Qld). She did not conduct any specific screening in relation to the presence of domestic and family violence within the relationship between Mr and Mrs Schulte and was unable to produce any contemporaneous notes of her counselling sessions. She said that she had done so but had since shredded the notes, consistent with her usual practice.

37. It was Ms J’s professional obligation to screen for the presence of domestic and family violence and make appropriate disclosures to the relevant authorities. Had this had happened, it may well have resulted in the authorities, or more specifically the Queensland Police Service in acting by applying for a domestic violence order.

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38. The Queensland Police Service failed to seek a Protection Order pursuant to the Domestic and Family Violence Protection Act 2012 (Qld), naming Mr Schulte as the Respondent, Mrs Schulte as the Aggrieved and their sons as named persons.

The effect of such an order would have immediately revoked Mr Schulte's capacity to hold weapons.

39. Despite an informal agreement made by Mr Schulte with police on 30 November 2018 that he would store the guns at a location other than his home, Mr Schulte remained in control of the firearms he was lawfully entitled to possess.

40. The evidence revealed that Mr Schulte had made the initial arrangement to store his guns at the residence of his friend, Troy Schonenberg. That agreement was reached after police telephoned Mr Schonenberg on 30 November 2018 to confirm he was willing to store Mr Schulte's weapons.4 3F

41. However, Mr Schonenberg never received Mr Schulte's weapons. Mr Schulte told him that he had another friend who would store them, and that he would go to the police and tell them he was going to store the weapons elsewhere.5 4F

42. Mr Schulte subsequently moved his firearms from 21 Julago Street to the address of his friend, Mr Hume. Mr Hume could not recall precisely when this occurred, but agreed it was in late November or early December 2018.6 Mr Hume did not hear 5F from Mr Schulte again until around Christmas Eve, when Mr Schulte telephoned him and advised he was taking his boys to his mother's place at Gumlu to go shooting. Mr Hume informed Mr Schulte he would not be at home. However, he told him where the keys for the gun safe were located. He invited Mr Schulte to retrieve the guns from his safe in his absence.7 6F

43. Mr Hume’s evidence was that Mr Schulte removed two of the three guns that he had stored in Mr Hume's gun safe - an air rifle and a '22'. Mr Schulte did not take the 'big gun' (Mossberg).8 7F

44. An agreement was reached between Mr and Mrs Schulte about the arrangements for their sons over the Christmas period. It was agreed that Mrs Schulte would take the boys to Mr Schulte's house on Christmas Eve and would collect them again at 11:00am on Christmas Day.9 8F

45. When Mrs Schulte delivered the boys to Mr Schulte just before lunchtime on Christmas Eve she stayed inside her car. While parked out the front of Mr Schulte's house, Mr Schulte made comments to Mrs Schulte, including that she was not going to see her children again. He said: "you're a fucken whore and a slut" and "there's nothing you could do about it.”10 Mrs Schulte immediately went to the 9F police station.11

10F 4 Transcript: 1-61 lines 20 - 35 5 Transcript: 1-61 lines 23 - 30 6 Transcript: 1-63 lines 8 – 12 7 Transcript: 1-64 lines 17 - 24 8 Transcript: 1-64 lines 40 - 46 9 Transcript: 1-17 lines 23-28 10 Transcript: 1 -18 lines 1-14 11 The circumstances of which are set out in detail under the heading 'Issue 4 -The Events of 24 December 2018' Findings of the inquest into the death of John Fredrick Schulte page 6 of 26

46. On the evening of Christmas Eve the boys made a video-call to their mother. At the end of the call Mr Schulte took the phone and called Mrs Schulte 'a fucken slut'.12

11F

47. On Christmas morning Mrs Schulte went to church to 'pray to god she would see her kids again'.13

12F

48. In accordance with the agreement, Mrs Schulte collected the boys from Mr Schulte's home at 11:00am. While putting the boys into Mrs Schulte's car, Mr Schulte said to her: "I hate you. I hate you. I hate you .... You need to go with your Mum now. I know that she's a dragon but just be good."14 Mrs Schulte drove to her parents' home where she celebrated Christmas.1513 F

14F

49. Later that afternoon Mrs Schulte left her parents’ home and returned to her home with her sons. Upon arriving home she noticed there were beer cans in the driveway, mail had been ripped up and shoved in the letter box and statues had been kicked over. Mrs Schulte assumed Mr Schulte had been at her home.16

15F

50. Mrs Schulte took the boys inside as they were tired. As she was laying down on the bed with her youngest son, Mrs Schulte started receiving picture messages from Mr Schulte.

51. The picture messages depicted Mr Schulte holding a bullet, Mr Schulte holding a bullet to his temple, one where Mr Schulte was loading the gun and one with Mr Schulte with the barrel of the gun under his chin.17 These messages were received

16F at 5:42pm.

52. Mrs Schulte understandably panicked and phoned 000.18 The call was received at 5:42pm by police communications.19 17F

18F

53. At 5:55pm police arrived at Mr Schulte's address, set up a cordon and attempted to negotiate with Mr Schulte.

54. There were three attempts to contact Mr Schulte by telephone. The first two were unsuccessful. The third was at 6:15pm. Mr Schulte answered and informed police that he did not really want to talk and hung up.20

19F

55. At 6:34pm that evening Mrs Schulte received a videocall from Mr Schulte. She answered the call and saw Mr Schulte with no shirt on and the barrel of the gun under his chin. He was saying "Look at me, look at me." Mrs Schulte immediately terminated the call and phoned 000.21

20F 12 Transcript: 1-20 line 20 13 Transcript: 1-20 line 33 14 Transcript: 1-20 line 40-45 15 Transcript: 1-20 line 47 16 Transcript: 1-21 lines 1-12 17 Transcript: 1-21 lines 20-25 18 Transcript: 1-21 line 30 19 Transcript: 1-41 line 5 20 Transcript: 1-43 line 17 21 Transcript 1-22 Findings of the inquest into the death of John Fredrick Schulte page 7 of 26

56. A police negotiator arrived at 6:45pm. At 7:02pm police heard what sounded like a gunshot from the upper level of the address. At 11:20pm the police ‘robot’ entered the upper level of 43 Findlater Street and located Mr Schulte with an apparent gunshot wound to his head.22 The butt of the firearm was located at

21F Mr Schulte's feet and the barrel toward his hands and head. The Queensland Ambulance Service pronounced Mr Schulte deceased at 11:38pm.

57. There was no evidence that Mr Schulte was suffering from a mental illness at the time of his death. He was clearly distressed about the breakdown of his marriage and the reduced contact with his sons. He had sought assistance, telling his doctor “he gets down at times”.23 The submission from the involved

22F QPS officers urged that a finding that his suicide was an act of domestic violence was based on conjecture. However, I accept the submission from Mrs Schulte that there is sufficient evidence to support a finding that the threats of suicide on 30 November 2018 and 25 December 2018, and the act of his suicide, were acts of domestic violence.

Issue 1 - Findings required by s. 45 of the Coroners Act

58. I am required to find, as far as possible, the medical cause of 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 – John Fredrick Schulte24

23F How he died – Mr Schulte had a history of threatening and attempting suicide in the context of domestic violence perpetration. This commenced before he entered the relationship with his wife, Samantha.

Mr Schulte became increasingly paranoid and controlling as Mrs Schulte started to achieve independence through success at work and university study. He closely monitored her movements and telephone calls. His continued threats that he would suicide, or shoot her and then shoot himself were acts of coercive control.

Although Mrs Schulte reported these threats and the details of Mr Schulte’s violence to a private psychologist and to the Queensland Police Service, no action was taken under the Domestic and Family Violence Protection Act 2012, including the confiscation of Mr Schulte’s registered weapons.

22 Transcript: 1-34 line 16 23 Exhibit E1 24 Mr Schulte was identified by way of fingerprint identification.

Findings of the inquest into the death of John Fredrick Schulte page 8 of 26

Mr Schulte intentionally shot himself on Christmas Day 2018 in an apparent act of domestic violence.

Place of death – 43 Findlater Street OONOONBA QLD 4811

AUSTRALIA Date of death– 25 December 2018 Cause of death – Gunshot wound to the head, with alcohol intoxication a significant contributing condition.

Issue 2 - The Police Response on 30 November 2018

59. On 30 November 2018, Mrs Schulte received a text message from Mr Schulte that was recorded in QPrime as saying: "I’ll say goodbye. tell the boys not to hate me for what I do".

60. Mrs Schulte telephoned police and reported her concern Mr Schulte was threatening suicide.25 Mrs Schulte expressed concern not only that Mr Schulte

24F had threatened to kill himself but also that he had access to firearms. She said he had attempted suicide previously. A few weeks earlier he said he would drive in front of a truck, and several years earlier he tried to hang himself and overdose. However, Mrs Schulte did not report the history or context of the relationship as being characterised by significant domestic and family violence.26

25F

61. Constables Sharon Molyneux and Brianna Palmer were assigned the job from police communications. While Constable Molyneaux told the inquest the job was initially received having been categorised as a 'welfare check', 27 it was

26F recorded in QPrime as being assigned codes “503 - Attempting/Threatening Suicide” and “312 - Domestic Violence”.28

27F

62. Upon arrival at the address of the 'informant' (Mrs Schulte), Constable Molyneux activated her body-worn camera. There was no one present at the address.29 Constable Molyneux accessed the QLite device and telephoned

28F Mrs Schulte. Constable Molyneux spoke with Mrs Schulte on the telephone and did not record the call. Constable Molyneux agreed that Mrs Schulte reported to her that she wanted Mr Schulte's weapons removed.30

29F

63. After a period of trying to locate Mr Schulte, Constables Molyneux and Palmer attended upon him at the roadside where he was working. They both activated their body-worn cameras. The conversation between Constables Molyneux and Palmer and Mr Schulte was recorded on the officers’ body-worn cameras.31

30F 25 Transcript: 1-10 line 1 26 Transcript: 1- 10 lines 16-24 27 Transcript: 1-67 line 15 28 Exhibit C9.2.5 29 Transcript: 1-68 line 9 30 Transcript: 1-69 lines 5-10 31 Exhibit D10 Findings of the inquest into the death of John Fredrick Schulte page 9 of 26

64. Mr Schulte told Constables Molyneux and Palmer that the message sent by him was not a threat of suicide but rather it referred to his intention to have sex with other women and he was sorry the boys would be exposed to other women. Mr Schulte explained that there was no sexual intimacy in the latter part of his marriage with Mrs Schulte. Constable Palmer told him he “shouldn’t have to put up with that shit”. Constable Molyneux commented: "you 're a saint for putting up with it for as long as you had. "32

31F

65. Mr Schulte also volunteered to the police officers: "My wife said I was going to shoot her and shoot myself". This had not been included in the information in the job card.33

32F

66. Constables Molyneux and Palmer were both aware that the message sent by Mr Schulte to Mrs Schulte had been interpreted as a threat of suicide, that he had previously attempted suicide ten years earlier, and that the threat of suicide reported by Mrs Schulte was made in the context of a relationship that was breaking down.34

33F

67. Constable Palmer believed Mr Schulte was not suicidal. She agreed with Constable Molyneux that there were not grounds for a domestic violence order, stating that if she believed domestic violence was occurring, she would have definitely done something about it.35

34F

68. Constable Palmer defended her decision not to conduct a DV-PAF assessment because 'DV wasn't alleged.'36 Constable Palmer also maintained

35F that the job was correctly categorised as a welfare check, rather than a domestic violence incident.37

36F

69. They consulted with Domestic Violence Liaison Officer, Sergeant Elise Feltham, and concluded that there were insufficient grounds to request either an EEA (Emergency Examination Application) or a Temporary Protection Order.38 They also concluded that there were insufficient grounds to take out a Police 37F Protection Notice.39

38F

70. Sergeant Feltham had no independent recollection of being contacted by Constable Molyneux, nor was there a record of the discussion in QPrime, or elsewhere. Sergeant Feltham's evidence was that at that time her Unit did not have the capacity to record every call for advice that was received.40

39F

71. Police contacted Mrs Schulte later that day by telephone. A female police officer (Constable Molyneux) reported that they had been to see Mr Schulte and that it was not a threat of suicide. Mrs Schulte learned that Mr Schulte reported to police that his message was not a threat, but a reference to his intention to date other women, and that there would be other women around 32 Transcript: 1-73 line 43 33 Transcript: 1-76 line 13 34 Transcript: 1-7 lines 7-33 35 Transcript: 2-45 lines 8-27 36 Transcript: 2-46 line 3 37 Transcript: 2-47 line 40 38 Transcript: 1-74 lines 7-15 39 Transcript: 1-70 line 34 40 Transcript: 2-3 lines 37-45 Findings of the inquest into the death of John Fredrick Schulte page 10 of 26

her house. Constable Molyneux told Mrs Schulte that it was a tough time of year to be going through a separation and that Mr Schulte was upset.41

40F

72. Constable Molyneux informed Mrs Schulte that Mr Schulte had agreed to take the guns to an address at the Burdekin which was over 100km away. Mrs Schulte stressed to the police that Mr Schulte had previously tried to hang himself and overdose and was trying to get the police to understand that he actually was him threatening to kill himself.42

41F

73. Mrs Schulte understood from that point onwards that the guns had been moved to the Burdekin.43

42F

74. Constable Molyneux did not record the second conversation that she had with Mrs Schulte.44 Following the decision made collectively by Constables

43F Molyneux and Palmer and Sergeant Feltham, the occurrence was recorded as a 'street check' .45

44F

75. After this incident Mrs Schulte arranged for her father to put deadlocks on the windows and a large lock on the gate.46

45F Appropriateness of the Police Response

76. The operational requirements in relation to the use of body-worn cameras are contained in the Digital Electronic Recording of lnterviews and Evidence Manual at part 4.4 (When to use a BWC). The policy states police officers should commence a recording as soon as practicable after an officer reasonably believes they may exercise a police power under legislation or apply a use of force.

77. BWC recordings are also to be made when the “recording might assist in providing a record of evidence which assists in the investigation of an offence or suspected offence; or the officer believes the interaction should be recorded”.

78. Neither of the two conversations between Constable Molyneux and Mrs Schulte on 30 November 2018 were recorded as the officers regarded the attendance as a welfare check.

79. Constable Molyneux accepted that her comment to Mr Schulte that he 'was a saint for putting up with it for as long as he had' was not appropriate.47 She

46F accepted that there was an awareness in her mind that the incident may have involved domestic violence.48

47F

80. I agree with the submission from Mrs Schulte that such comments, while appearing to be an effort to build rapport, may have created the perception that the officers shared Mr Schulte’s beliefs and emboldened his actions.

41 Transcript: 1-10 lines 30-37 42 Transcript: 1-10 line 43 to 1-11 line 4 43 Transcript: 1-11 line 28 44 Transcript: 1-73 line 19 45 Transcript: 1-74 line 17 46 Transcript: 1-11 lines 38-42 47 Transcript: 1-74 lines 1-3 48 Transcript: 1-75 line 43 Findings of the inquest into the death of John Fredrick Schulte page 11 of 26

81. This was demonstrated by the fact that after his interaction with Constables Palmer and Molyneux, between 1:12pm and 9:00pm on the evening of 18 November 2018, Mr Schulte sent Mrs Schulte a total of 54 text messages. One of the text messages he sent on that day indicated: “I told the cops y I think you are a lesbian an thay agreed with me”.

82. Despite Mr Schulte volunteering that his wife said that he 'threatened to shoot her and himself’, these comments were not recorded in the occurrence report.49

48F

83. Constable Molyneux was aware that threats of suicide and threats to shoot Mrs Schulte could constitute domestic violence.50 She accepted that there

49F were other risk factors for domestic violence present, such as threatening the use of a weapon and recent separation, but she did not recognise those on the day.51

50F

84. Constable Molyneux’s evidence was that she has since had more experience, but at the time she did what she thought was right.52 Constable Molyneux was

51F the subject of Local Management Resolution during which she was required to speak with a superior officer about domestic violence and participate in further training. She was scheduled to participate in this face-to-face training in August 2022.53

52F

85. Constable Palmer’s evidence was that notwithstanding the comments that were made by Constable Molyneux about whether there were grounds for an order, this did not cause her to reconsider whether the job was appropriately categorised.54 She said that looking back at it now and knowing what

53F happened she would change things, but at that point she did not have anything else to go on.55

54F

86. Constable Palmer said she was also the subject of Local Management Resolution for her failure to investigate and identify apparent risks of domestic violence. This involved a discussion with Senior Sergeant Gavin Oates.

Constable Palmer was told she would need to participate in training. As at the date of the inquest this had not occurred.56

55F

87. Sergeant Rhodes considered that this incident should have been recorded as a domestic violence occurrence rather than as a welfare check. He found there was not enough information to warrant an application for a protection order; however, ‘some sort of DV occurrence should have been created and the incident should have been investigated as DV’.

49 Transcript: 1-76 line 32 50 Transcript: 1-76 line 35 51 Transcript: 1-77 line 14 52 Transcript: 1-78 lines 3-5 53 Transcript: 1-78 lines 40-45 54 Transcript: 2-48 line 23 55 Transcript: 2-48 line 26 56 Transcript: 2-72 line 15 - 2-73 line 32 Findings of the inquest into the death of John Fredrick Schulte page 12 of 26

88. On the other hand, both Acting Snr Sergeant Evans and Mr O’Regan considered that the primary focus of the attending officers was on Mr Schulte’s welfare and that the welfare check conducted was thorough and addressed the needs of Mr Schulte at the time of their interaction. Acting Snr Sgt Evans noted that Mr Schulte’s disclosure that he had threatened to shoot his wife and then kill himself was a type of comment ‘often used by respondents in a DV context as a way of exerting coercive control over their victims’, but ‘thought sufficient follow up questioning and appropriate measures were put in place by the officers to negate this comment’. Mr Schulte agreed to a police referral for assistance with his marriage breakdown.57 Mr Schulte also sought a Mental

56F Health Care Plan from his GP on 19 November 2018 to assist with his wellbeing in the context of his relationship breakdown.58

57F

89. I consider that the police response to the callout made on 30 November 2018 was inappropriate. While the officers said that the job card only referred to a welfare check because of a reported suicide threat, code “312 - Domestic Violence” had also been recorded in QPrime.

90. The information Mr Schulte communicated to Constables Molyneux and Palmer revealed key indicators of risk of domestic and family violence. This included Mr Schulte advising them that his wife had alleged he would shoot himself and shoot her, there was a recent separation, a previous suicide attempt and children of the relationship. These risk factors are all articulated in the DV-PAF.

91. At the very least, this occurrence should have been finalised as 'DV- Other.' While there may not have been sufficient grounds for a Police Protection Notice or a Temporary Protection Order at that time, there was sufficient information for the occurrence to have been categorised as related to domestic and family violence. The finalisation of the occurrence as a Street Check meant that it was not reviewed by a senior officer as a domestic violence incident. Neither was it identifiable in police records as a domestic violence incident.

Issue 3 – The police response on 17 December 2018

92. On 17 December 2018 Mrs Schulte went home from work as she was unwell and went to sleep. She awoke to the noise of banging from downstairs. Mr Schulte was demanding to be let in. Mr Schulte could not use his key because deadlocks had been placed on the door. Mrs Schulte opened the door.59 She

58F told police that Mr Schulte had turned up at the house to get some clothes. She told him that there were rules in place for him to call her and get her permission before he attended the house. He replied that the house was still his, and that he needed clothes.

57 He followed up on this referral but was unable to secure an appointment until January 2019.

58 Exhibit E1, page 16 59 Transcript: 1-12 lines 28-42 Findings of the inquest into the death of John Fredrick Schulte page 13 of 26

93. Mr Schulte went into the kitchen and was saying "I've caught you; I've caught you”. This was in the context of Mr Schulte believing that Mrs Schulte was having an affair. Mr Schulte proceeded to pull things out of the wardrobes and look under the bed. He said: "You're a fucking slut and a whore. You can't keep your legs closed. Fuck you."60

59F

94. Mrs Schulte was feeling ill and stated the worst thing you could do was 'have a go back', so she just stood there. Mr Schulte said he would be back. He stormed out, did a burnout and took off. Mrs Schulte phoned police.61

60F

95. While waiting for the police to attend, Mrs Schulte recalled being phoned by a female police officer who asked her whether she still wanted the police to attend. Mrs Schulte confirmed she did.62 It can be inferred that this could only

61F have been Constable Palmer as she was the only female police officer involved in the callout. Constable Palmer 'could not remember' whether she called Mrs Schulte before attending her home.63

62F

96. Constables Palmer and Clark attended the callout. Neither of them activated their body-worn cameras despite it being an operational requirement to do so.64

63F

97. Because she was feeling 'really, really sick', Mrs Schulte asked Constables Palmer and Clark to come inside so she could sit down and explain what had occurred. They sat on the couch and Mrs Schulte attempted to explain the background to Mr Schulte's behaviour. She told the officers that she had been unable to shower alone. She also told them about the rape and sexual assaults and the constant telephone calls culminating in Mr Schulte arriving at the house. She explained that Mr Schulte was looking under the bed and, in the wardrobe, and she told them that he had threatened to shoot her.65

64F

98. Mrs Schulte recalled the female police officer (Constable Palmer) said: "Oh yes, I was the one that attended on - with the initial suicide threat. "66 Mrs

65F Schulte told the police officers about Mr Schulte threatening to shoot her.

When asked when it occurred, Mrs Schulte replied: 'September.' She was then questioned about why she did not report it then.67

66F

99. Mrs Schulte went through her phone and showed the police officers the exact message that Mr Schulte sent her where he threatened to shoot her.68

67F

100. At the same time Mrs Schulte told the police officers what had happened that day. She said Mr Schulte was paranoid because he had been accusing Mrs Schulte of ‘being places’. When Mrs Schulte referred to the guns, Constable Palmer said: "Didn't the guns go to the Burdekin?" Mrs Schulte replied that she did not know where they were.69

68F 60 Transcript: 1-13 lines 1-4 61 Transcript: 1-13 line 7 62 Transcript: 1-13 lines 12-15 63 Transcript: 2-49 line 17 64 Transcript: 2-50 lines 1-10 65 Transcript: 1-13 lines 30-37 66 Transcript: 1-13 line 38 67 Transcript: 1-13 lines 42-44 68 Transcript: 1-14 lines 1-3 69 Transcript: 1-14 lines 24-28 Findings of the inquest into the death of John Fredrick Schulte page 14 of 26

101. Mrs Schulte’s evidence was that she was 'petrified that he was going to shoot me.' She showed the police officers where the gun safe had been ripped out.

Mrs Schulte was not confident that the guns had been moved to the Burdekin by 17 December 2018.70

69F

102. Mrs Schulte recalled being asked by police what she wanted them to do. She advised she would like a 'DVO' (Domestic Violence Order). Mrs Schulte recalled that Constable Palmer indicated that she thought that was what they would do. The police officers then left to attend upon Mr Schulte.71

70F

103. Constable Palmer's recollection of the conversation with Mrs Schulte was that she reported Mr Schulte turned up at the house and tried to go inside. He called her a slut. Mrs Schulte reported that Mr Schulte had been texting her a few times, and that three months ago he had threatened to shoot her.

104. Constable Palmer alleged Mrs Schulte said she was not afraid of Mr Schulte and did not believe he would go through with the threat.72 Constable Palmer did

71F not recall that Mrs Schulte had reported she was the victim of rape and sexual assaults.73

72F

105. However; when reminded about the interview she participated in with Ethical Standards, Constable Palmer recalled that Mrs Schulte had in fact reported to her that she was the victim of sexual assault.74 She agreed she should have asked more questions about that.75 73F

74F

106. Constable Palmer formed the view that it was not necessary or desirable for a Police Protection Notice to be put in place. Rather, she advised Mrs Schulte to attend the DV Resource Centre.

107. After the police left, Mrs Schulte received a text message from Mr Schulte which said: "did you gall the coppers on me. "76

75F

108. Constables Palmer and Clark attended upon Mr Schulte and activated their body-worn cameras. Mr Schulte told Constables Palmer and Clark that he had moved the guns. This was accepted at face value.77 Later, upon returning to

76F Mr Schulte and advising him that a decision had been made not to take out an order, Constable Palmer said: "You don't want to get your weapons taken off you. You don't deserve it. "78

77F

109. Constables Palmer and Clark discussed the matter and agreed that there were insufficient grounds to take out an order.

70 Transcript: 1-14 lines 25-35 71 Transcript: 1-14 line 45 -1-15 line 4 72 Transcript: 2-50 line 15 73 Transcript: 2-54 lines 26 - 32 74 Transcript: 2-55 line 2 75 Transcript: 2-55 line 9 76 Transcript: 1-15 line 3 77 Transcript: 2-58 line 37 78 Transcript: 2-62 line 28 Findings of the inquest into the death of John Fredrick Schulte page 15 of 26

110. Constable Palmer contacted the District Duty Officer ('DDO') to obtain approval to categorise the occurrence as 'DV- Other'. The DDO that day was Senior Sergeant Joe Matheson. She recalled reporting to Senior Sergeant Matheson that Mr Schulte had attended the home to obtain property. Mr Schulte did not expect Mrs Schulte to be there and was not expecting conflict.79

78F

111. Constable Palmer could not remember whether she told the DDO about the earlier occurrence of 30 November 2018, whether Mrs Schulte was the victim of rape or sexual assault, or whether Mrs Schulte had reported that Mr Schulte was following her. Constable Palmer 'would have said' to the DDO that Mrs Schulte had reported a number of text messages had been sent to her by Mr Schulte.80

79F

112. Senior Sergeant Matheson's evidence was that Constable Palmer told him that Mr Schulte attended the residence to get some clothing. There had been some mention of a firearm and threats to shoot. He was not made aware of the earlier callout on 30 November 2018. He was not told that Mr Schulte was making threats to shoot himself, and was not made aware the informant was crying.

Senior Sergeant Matheson was initially inclined to taking out a Domestic Violence application. However, Constable Palmer convinced him that there were insufficient grounds to take out a Protection Order.81

80F

113. Constables Palmer and Clark then returned to Mr Schulte and advised him that a decision had been made not to take out an order.82

81F

114. Constables Palmer and Clark later returned to Mrs Schulte's home, where they told Mrs Schulte that 'Mr Schulte was getting his act together'. They explained that he had obtained rental accommodation, and while they were aware that what he was doing to her amounted to domestic violence, they were going to give him one last chance and were not going to take out a Domestic Violence Order.83

82F

115. Mrs Schulte recalled asking herself whether this was 'normal'. She questioned how much more she was meant to put up with. She felt shocked, and thought Mr Schulte was going to kill her.84

83F

116. The incident was logged as 'DV - Other'. The DV-PAF and occurrence report were not done until after Constables Palmer and Clark returned to the police station.85

84F

117. Constable Clark created the occurrence and Constable Palmer was responsible for writing the narrative. Constable Clark entered the details into the DV-PAF. Both were severely lacking in detail and the recording of risk factors reported by Mrs Schulte. There was no reference in either the occurrence report or the DV-PAF to there being sexual assaults reported, previous suicide attempts, and access to weapons. While the 'fearful' box was 79 Transcript: 2-60 line 24 80 Transcript: 2-60 line 10 - 2-62 line 15 81 Transcript: 3-87 line 40 - 3-90 line 40 82 Exhibit D1 83 Transcript: 1-15 lines 12-24 84 Transcript: 1-15 lines 24-30 85 Transcript: 2-64 line 7 Findings of the inquest into the death of John Fredrick Schulte page 16 of 26

ticked in the DV-PAF, it was not referred to in the occurrence report and the evidence of Constable Palmer was to the contrary.

118. Constable Palmer was asked in her ESC interview about whether Mrs Schulte appeared to be concerned about her welfare, and Constable Palmer indicated that she was not, and she “got the impression she was calling us for family law court purposes…”.

119. Constable Palmer appeared to be of the view that if Mrs Schulte was fearful, she would have called the police when the threat to shoot her was made. She stated that she did not believe there was domestic violence between Mr and Mrs Schulte, and that “…if [the threat] did happen and she was fearful she would have called police when it did”. Constable Palmer’s evidence with respect to the express question and statements about fear was not supported by, or is inconsistent with, that of both Constable Clark and Mrs Schulte. Their evidence is to be preferred.

The Appropriateness of the Police Response

120. Neither Constable Clark nor Constable Palmer activated their body-worn cameras when they attended upon Mrs Schulte to receive her report of domestic violence. This represented a departure from police policy. If the officers had recorded the conversation, there would be no room for the discrepancy between their versions and what was reported by Mrs Schulte.

121. Mrs Schulte reported to Constables Palmer and Clark significant risk factors associated with domestic and family violence. These included threats to kill, access to weapons, a recent threat of suicide, rape and sexual assault, harassment by repeated text messages and telephone calls which were shown to them. She told the officers Mr Schulte had followed her and he turned up at her home that day unannounced and uninvited. Mrs Schulte was upset and crying. Constable Clark acknowledged she was fearful, but Constable Palmer said she reported not being fearful.

122. The DV-PAF was not conducted at the time of the initial callout to Mrs Schulte or while discussing the matters with Mr Schulte. This also represented a departure from policy.

123. Similarly, Constable Palmer did not accurately relay the matters reported by Mrs Schulte to the District Duty Officer, Senior Sergeant Matheson. He was initially inclined to bring an application for a DVO against Mr Schulte but Constable Palmer persuaded him it was not necessary. There is little doubt that if Constable Palmer reported each of the relevant indicators of domestic violence to Senior Sergeant Matheson, the outcome would have been different and an order taken out.

124. Sergeant Rhodes considered that this incident should have resulted in a police application for a protection order.86 Acting Sergeant Evans also said that

85F consideration should have been given to a Police Protection Notice or some other action to secure a domestic violence order.

86 Transcript: 3 - 32 line 45 Findings of the inquest into the death of John Fredrick Schulte page 17 of 26

125. Mr O’Regan said that he considered the QPS response on this occasion to be appropriate. This was because, consistent with their training, the officers were “not looking at it at it holistically and that may be problematic, but they were looking at it as an incident… “This is the job I’m doing now.”87

86F

126. The failure to record the rape and sexual assault complaints in the occurrence report subsequently had distressing consequences for Mrs Schulte. Her initial claim for assistance from Victim Assist Queensland was rejected on the grounds that she had not made reports to police when in fact she had. The fact that there was no record of these reports was associated with the inaction and poor reporting from Constables Palmer and Clark. The substantial oversight in failing to accurately report Mrs Schulte's complaints highlights the serious consequences of lack of reporting and the need to properly document all complaints.

127. I agree with the submission from Counsel Assisting that the constellation of factors reported by Mrs Schulte on 17 December 2018, coupled with the earlier recent report of 30 November 2018, resulted in more than sufficient evidence for a Police Protection Notice to be taken out. The fact that it was categorised as a 'DV- Other' was entirely inappropriate and ignored the serious and escalating nature of domestic violence being perpetrated against Mrs Schulte by Mr Schulte.

128. The occurrence ought to have been logged as 'DV- Action', at which time an urgent Police Protection Notice would be sought. The officers’ inappropriate handling of the situation resulted in a missed opportunity to protect Mrs Schulte and to remove Mr Schulte’s firearms from his possession.

129. Constable Clark was the subject of Local Management Resolution which required him to participate in training specific to domestic and family violence. He did not participate in such training until September 2021, when he assumed the role of the Domestic and Family Violence Liaison Officer. He took part in training with Sergeant Feltham and other district Domestic Violence Liaison Officers.88

87F

130. Despite the personal stressors faced by Constable Palmer since her involvement in the incidents of 30 November 2018 and 17 December 2018, it was of some concern that by late 2022 she had not participated in training in relation to domestic and family violence, as recommended as a part of her Local Management Resolution.

Issue 4 - The police response on 24 December 2018

131. When Mrs Schulte delivered the boys to Mr Schulte just before lunchtime on Christmas Eve she remained inside the car. While parked at the front of Mr Schulte's house, Mr Schulte made comments to Mrs Schulte, including that she was not going to see her children again. He said: "you're a fucken whore and a slut" and "there's nothing you could do about it. "89 Mrs Schulte

88F immediately went to the police station.

87 Transcript: 3 - 79 line 25 88 Transcript: 2-118 line 10 - 2-119 line 15 89 Transcript: 1-18 lines 1-14 Findings of the inquest into the death of John Fredrick Schulte page 18 of 26

132. Upon arrival at the Stuart Police Station, Mrs Schulte was taken into a room with Senior Constable D, a specialist Domestic and Family Violence Liaison Officer.90 The interaction between Mrs Schulte and Senior Constable D was capture 89F d on body-worn camera.91

90F

133. Mrs Schulte reported the incident from that morning and her fear in relation to the safety of her children. She explained that there were not any parenting orders in place, or a Domestic Violence Order. Mrs Schulte also reiterated her concern about the whereabouts of Mr Schulte’s weapons. A discussion occurred about grounds for a Domestic Violence Order. Mrs Schulte explained she intended to apply for an order privately, but the courts were closed because it was Christmas Eve.92

91F

134. Mrs Schulte told Senior Constable D that she had been raped by Mr Schulte and indicated that she did not wish to make a formal complaint of a criminal nature.93 Mrs Schulte also stated repeatedly that Mr Schulte:

92F

• had threatened her, including threatening to shoot her and to kill himself;

• had threatened to “take off” with the children;

• was very controlling and said negative things about her to the children.

135. Mrs Schulte appeared visibly distressed. She was crying. There was a sense of urgency and desperation in her voice. Senior Constable D logged the incident as a Street Check. SC D informed Mrs Schulte “if I did have to take [the kids] off one of you then they go to DOCS94, they don’t go to the other parent.”

93F

136. SC D concluded that “Based on the non-specific “threats” and the length of time since anything significant has occurred”, and the informant not wanting police to take up with Mr Schulte, a street check had been generated. She did not apply the DV- PAF and took no further action.

The Appropriateness of the Police Response

137. The occurrence report compiled by Senior Constable D failed to identify or record the continuous threats made by Mr Schulte and the long history of domestic violence.

138. At the inquest, Senior Constable D frankly conceded that her response to Mrs Schulte was inappropriate. Senior Constable D said she should have investigated further and potentially arrived at the conclusion that immediate action be taken in the form of a Police Protection Notice.95

94F

139. Sergeant Rhodes and Senior Sergeant Evans also considered that this incident should have resulted in a police application for a protection order because of the serous nature of the allegations and a domestic violence occurrence commenced.

Mr O’Regan agreed that the incident should not have been recorded as a police 90 A non-publication order was made in relation to this officer.

91 Exhibit D12 92 Transcript: 1-19 lines 32 - 44 93 Exhibit D12 (Transcript) page 6 94 The Department of Child Safety 95 Transcript: 3-22 line 20 Findings of the inquest into the death of John Fredrick Schulte page 19 of 26

check but was not certain action in the form of a police protection order was warranted on that particular day.96

95F

140. While Senior Constable D defended her decision to log the occurrence as a Street Check during her interview with Ethical Standards Command, her evidence at the inquest was that she had since participated in and completed additional targeted studies. With the benefit of hindsight, she was sure she would do things differently.97

96F

141. The studies Senior Constable D referred to were completed in her own time and at her own expense.98 This is commendable. Senior Constable D had also

97F sought private professional assistance from psychologists. I agree that this recognises the profound impact her involvement in the circumstances that led up to Mr Schulte's death had upon her.

142. I am satisfied that Senior Constable D has demonstrated that her actions and inaction on 24 December 2018 fell short of accepted policing practice. She demonstrated a real degree of insight and had taken steps personally to address these issues.

143. Senior Constable D has plainly learnt valuable lessons from her involvement in this incident and her subsequent training. I agree she possesses the necessary experience and insight to be a valued Domestic Violence Liaison Officer within the Queensland Police Service in the future.

144. Notwithstanding, the police inaction on 24 December 2018 was entirely inappropriate. The risk factors identified in the interview with Mrs Schulte, coupled with the earlier police occurrences of 30 November 2018 and 17 December 2018 and all other known factors ought to have resulted in an urgent Police Protection Notice being served immediately upon Mr Schulte.

Issue 5 – QPS communication with Mrs Schulte on and from 25 December 2018

145. After Mrs Schulte's initial complaints of text messages with images threatening suicide were made in her 000 call, Senior Constable Warner contacted Mrs Schulte at the request of the Communications Coordinator, Senior Sergeant Alberich.99 Senior Constable Warner was the Assistant Communications

98F Coordinator.

146. Senior Constable Warner asked Mrs Schulte to forward the picture messages Mr Schulte had sent to her phone and forwarded them to Senior Sergeant Alberich.

147. Mrs Schulte recalled telephoning 000 at which time the operator told her to stop phoning. She was concerned at the time because she did not know whether Mr Schulte was going to shoot her, and did not know where he was.

96 Transcript: 3-80 line 20 97 Transcript: 3-22 line 1-10 98 Transcript: 3-28 line 35 99 Transcript: 1-50 line 38, 1-51 line 5 Findings of the inquest into the death of John Fredrick Schulte page 20 of 26

She had been told the day before that he did not have his guns, when in fact he did.100

99F

148. Senior Sergeant Alberich received a telephone call from Mrs Schulte at 9:17pm. By that time he was aware that Mr Schulte was deceased. He did not communicate that to Mrs Schulte because it was not 'actually confirmed' at that point in time.101

100F

149. At approximately 10:30pm on Christmas evening, Mrs Schulte recalled two female plain clothes police officers attending at her home. When she asked them whether Mr Schulte was alive, they said that they were trying to work out the situation. Mrs Schulte was required to go through her history once again.102

101F

150. In the early hours of 26 December 2018, police attended Mrs Schulte's residence and advised her that Mr Schulte was deceased. She was home alone with her sons at the time.103 The police did not advise Mrs Schulte of how he had died.104 102F

103F

151. In the interview between Mrs Schulte and Detective Sergeant Schmidt from the Ethical Standards Command on 26 December 2018, Mrs Schulte was advised that Mr Schulte died of a gunshot wound. It was not specified whether it was fired by police or was self-inflicted.105

104F

152. Detective Sergeant Schmidt released the information was authorised to.106 105F

153. It was not until 21 January 2019 that Mrs Schulte learned through a letter that Mr Schulte had died by a self-inflicted gunshot wound to the head. This letter was received on Mr Schulte's 40th birthday. Mrs Schulte vomited upon opening the letter.107

106F

154. Mrs Schulte had a limited recollection of the precise events that transpired in the days and weeks after Mr Schulte's death. She recalled that she did not know what happened and the contact from police was 'sporadic' .108

107F

155. It was submitted by Mrs Schulte that I consider making a recommendation that the “QPS develop and implement processes by which suitably qualified persons can be engaged to act as a liaison between the QPS and families in appropriate circumstances, such as where those families have been significantly impacted by trauma but are required to participate in an ongoing police investigation”.

100 Transcript: 1-22 lines 16-20 101 Transcript: 1-43 line 17 102 Transcript: 1-23 lines 5-10 103 Transcript: 1-23 lines 15-24 104 Transcript: 1-23 line 22 105 Transcript: 3-8 and Exhibit D25 106 Transcript: 3-44 line 25 107 Transcript: 1-23 lines 35-42 108 Transcript: 1-25 line 4 Findings of the inquest into the death of John Fredrick Schulte page 21 of 26

156. Coronial counsellors employed by Queensland Health Forensic and Scientific Services provide support to families for deaths managed out of the FSS complex at Coopers Plains. Unfortunately, this does not automatically extend to deaths managed by regional mortuaries. FSS is currently in the process of implementing a statewide model of service which would ensure that the information and support needs of family members such as Mrs Schulte are met in regional areas.

157. In addition, the information needs identified by Mrs Schulte would generally be met by a Family Liaison Officer appointed by the Ethical Standards Command.

It appears that such an officer was not appointed in this matter. The relevant ESC instructions were updated in 2022.

158. In those circumstances, I am not persuaded that the recommendation sought by Mrs Schulte is required.

Issue 6 - Appropriateness of the Review Process by specialist officers

159. Sergeant Elise Feltham gave evidence at the inquest. At the time of these events Sergeant Feltham was the Domestic and Family Violence Coordinator for the Townsville District. Her position changed with the creation of the Vulnerable Persons Unit in Townsville in 2020. Townsville did not previously have a Vulnerable Persons Unit.

160. As the Domestic and Family Violence Coordinator, Sergeant Feltham was to oversee, as best as she could, the work of the frontline officers who had attended callouts relating to domestic and family violence.109

108F

161. As at 2018, there were only two persons employed to participate in the review process; Sergeant Feltham and one part-time employee, Senior Constable Lyons. The District Officer requested that Sergeant Feltham and Senior Constable Lyons review between twenty to fifty percent of the officers’ work at random, and identify any issues.110

109F

162. Sergeant Feltham's evidence was that since that time, the Queensland Police Service response had 'improved dramatically' because there are now thirteen (13) officers in the unit.111 She said that in 2018, the QPS was very

110F incident-focussed, whereas now the training which is being undertaken requires officers to take a more holistic approach to domestic and family violence.112

111F

163. In 2018 there was concern within the QPS that first responder officers were not correctly using the DV-PAF. This is the DV 'Protective Assessment Framework' which is a tool utilised on a QLite device and designed to assist with identifying risk factors that indicate domestic and family violence.113 Sergeant Feltham attributed this to a lack of training.114 112F

113F 109 Transcript: 2-18 line 25 110 Transcript: 2-3 lines 18-23 111 Transcript: 2-3 line 47-2-4 lines 1-7 112 Transcript: 2-7 lines 34-43 113 Transcript: 2-10 lines 25 - 45 - 2-11 line 36 114 Transcript: 2-10 line 47 Findings of the inquest into the death of John Fredrick Schulte page 22 of 26

164. The review process in 2018 was limited because the Queensland Police Service was significantly under-resourced. Sergeant Feltham did not have the capacity to review more than between twenty to fifty percent of all domestic violence occurrences. This was limited to QPrime entries and did not involve reviewing body-worn camera footage, which would be more time consuming and burdensome upon police resources.115

114F

165. The evidence given at this inquest specific to the review of the appropriateness of the police occurrences on 30 November 2018, 17 December 2018 and 24 December 2018 was given from Acting Senior Sergeant Nicholas Evans, Sergeant Alastair Rhodes and Clement O'Regan.

166. The fact that their opinions differed about the appropriateness of the police responses highlights the subjective and complex nature of responding to domestic and family violence related occurrences.

167. I agree with the submission from Counsel Assisting that no specific finding about the divergence in their opinions is necessary because of the commitment of the Queensland Police Service to deliver a modern and targeted training model centred around trauma-informed, victim-centric policing of domestic and family violence. It is envisaged that this training will result in a more streamlined and comprehensive approach to domestic violence occurrences.

168. Mrs Schulte submitted I may see fit to recommend that, as part of any specialist review process, each interaction between persons involved in a domestically violent relationship be reviewed, regardless of whether it is finalised as a domestic violence incident or a street check. This will contribute to ensuring that an accurate and complete history of incidents in the relationship is captured on review, and will assist to ensure that important interactions in the relationship that have been recorded by police are not omitted from review merely on the basis that they are recorded as street checks.

169. These matters were considered in the Call for Change Report, which recognised that “Domestic and Family Violence Liaison Officers and Domestic and Family Violence Coordinators are important specialist roles with the potential to be an integral part of improving Queensland Police Service responses to domestic and family violence”.

170. The review process in 2018 was severely under-resourced and inadequate.

The increase in funding to specialist roles within Vulnerable Persons Units and additional positions in specialist domestic and family violence roles will ensure that future review of domestic violence occurrences occurs on almost all cases. It will be necessary for QPS officers to capture “an accurate and complete history of incidents in the relationship” in the context of responding to coercive control and patterns of violence over time. I agree that substantial change has already been made and further positive change is underway.

115 Transcript: 2-15 lines 26-40 Findings of the inquest into the death of John Fredrick Schulte page 23 of 26

Issues 7 & 8- Further Specialist Training & Preventative Changes

171. The police interactions with Mr and Mrs Schulte leading up to his death occurred in 2018. Since that time, two other inquests in Queensland have traversed similar issues in focusing on the appropriateness of police response to domestic and family violence.

172. Those inquests were the Inquest into the deaths of Doreen Gail Langham and Gary Mathew Hely, and the Inquest into the deaths of Hannah Clarke and her children. Both inquests were referred to by police witnesses who were either involved in those inquests or were aware of the findings.

173. In addition, the Queensland Government's Special Taskforce on Domestic and Family Violence report 'Not Now, Not Ever: Putting an end to domestic and family violence in Queensland' and the Women's Safety and Justice Taskforce 'Hear Her Voice' reports have also been instrumental in highlighting the past failures in policing domestic and family violence and in influencing change.

174. At the time this inquest was heard, the Independent Commission of Inquiry into Queensland Police Service responses to domestic and family violence was under way. The expert evidence given by Assistant Commissioner Brian Codd and Assistant Commissioner Mark Kelly at the Commission of Inquiry was tendered at this inquest,116 and was mirrored in their evidence before me.

115F

175. The Commission of Inquiry’s Report – A Call for Change was finalised in November 2022. The Report contained 78 recommendations which were all supported in principle by the Queensland Government. The report identified significant cultural issues within the QPS which inhibit the policing of domestic and family violence.

176. The implementation of the 341 recommendations from the Hear Her Voice and A Call for Change reports that were supported by the Government is being monitored by the Office of the Independent Implementation Supervisor. The Women's Safety and Justice Reform-Annual Report 2022-23 was tabled in the Parliament on 4 August 2023.

177. Legislation has been passed to address the patterned nature of coercive control in the definition of domestic violence.117 A standalone offence of coercive

116F control is expected to be introduced to Parliament later in 2023.

178. A new High Risk Team commenced operation in Townsville in July 2023 and more funding has been provided for men’s behavioural change programs. A coresponder model involving the QPS and specialist DFV services for domestic violence call outs will be trialled in Cairns.

116 Exhibits G3.1.3 and G4.4 117 Domestic and Family Violence Protection (Combating Coercive Control) and Other Legislation Amendment Act 2023 Findings of the inquest into the death of John Fredrick Schulte page 24 of 26

179. Relevant changes arising from the Call for Change report that have been implemented include that the QPS:

• has initiated a procedure which requires Officers in Charge to ensure that all frontline officers who attend domestic and family violence occurrences meet with a designated senior officer to receive feedback in relation to a sample of their body worn camera footage at least every six months.

• has approved the Domestic and Family Violence Mandatory Specialist Training Procedure. The Procedure establishes that five-day specialist training for the designated roles, as outlined in the recommendation, is mandatory.

• has reviewed and updated the list of support services to which officers can refer vulnerable people experiencing domestic and family violence.

• has started a review of all domestic violence policies and procedures, including a complete review and update of the QPS Operational Procedures Manual Chapter 9 – Domestic Violence.

180. The QPS is training its officers to shift from incident based responses to DFV to a victim-centric-trauma-informed ‘holistic approach’ to policing. Assistant Commissioner Kelly gave evidence of these changes as follows:

• DFV training for recruits in Brisbane and Townsville was expanded from nine days to 19 days from September 2022, including face-to-face training as well as scenario-based training and assessments, theory-based learning and lived experiences. This training incorporates the ‘holistic approach’ which is being adopted as the appropriate model by the QPS, as opposed to the traditional model of ‘What’s Important Now’;

• After recruits become first year Constables they will move from the traditional one day of DFV training in the first 12 months to a three-day program, including a focus on the DV-PAF;

• A three-day training program, incorporating the trauma-informed-victimcentric approach, rather than identifying a particular occurrence in isolation (the holistic approach) is being rolled out for all police up to the rank of Superintendent. This involves extensive face-to-face training in domestic and family violence which covers issues involving intimate partner sexual violence, stalking, strangulation, coercive control, the appropriate utilisation of the DV-PAF and the need to accurately report and record occurrences in QPrime;

• A five-day specialist training course, commencing in November 2022, substantially contributed to by external providers with the pragmatic approach of not turning every general duties police officer into a DFV expert. Rather, the training informs them as best as possible to understand the context of DFV as something bigger than ‘incident response’ and ‘first response’.

Findings of the inquest into the death of John Fredrick Schulte page 25 of 26

181. It was submitted for Mrs Schulte that the QPS should also develop and implement training for officers with respect to human rights considerations and obligations, in the specific context of policing of domestic and family violence. I note that the QPS is engaging with the Queensland Human Rights Commission in the implementation of the A Call for Change Report. The submission from the Commissioner also noted the QPS is willing to consider how to work human rights considerations into the current training platforms.

182. In the context of the 341 recommendations currently being implemented by the Government, I accept the submission from the Commissioner that the policing of domestic and family violence is rapidly evolving and that there are no further recommendations which I could reasonably make which have not already been addressed.

183. I also acknowledge that while there has been significant implementation and change within the Queensland Police Service since 2018, there will always remain a degree of human error associated with policing domestic and family violence related incidents. Police officers are required to exercise discretion in their work. Policing domestic violence requires nuanced approaches to each set of circumstances, responsive to the needs of the individuals involved.

184. There will always remain opportunities for improvement. The scale of the reforms required is set out in detail in the Call for Change Report. More and continued training and development are key to changing the culture and knowledge within the Queensland Police Service, so that officers better understand the complex issues involved in the policing of domestic and family violence.118

117F

185. I acknowledge the courage of Mrs Schulte in sharing her experience and participating in this inquest. She can be confident that her voice has been heard in this process and that she has contributed to enduring change.

186. I close the inquest.

Terry Ryan State Coroner

BRISBANE 118 Transcript: 2-22 lines 30-45 Findings of the inquest into the death of John Fredrick Schulte page 26 of 26