Coroner's Finding: QUINN Paul James

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 4th, 6th, 11th, 12th, 13th, 14th and 17th days of December 2012, the 4th day of February 2013, the 27th, 28th, 29th, 30th and 31st days of May 2013 and the 2nd day of October 2013, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Paul James Quinn.

The said Court finds that Paul James Quinn aged 31 years, late of 16 Dorothy Street, Brahma Lodge, South Australia died at 68 Norman Terrace, Forestville, South Australia on the 19th day of September 2010 as a result of gunshot wounds to liver, right lung and heart. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Paul James Quinn died on 19 September 2010. He was aged 31 years. An autopsy was conducted by Dr Carl Winskog of Forensic Science South Australia1. Dr Winskog gave the cause of death as gunshot wounds to liver, right lung and heart, and I so find.

1.2. At the time of Mr Quinn’s death he was attempting to evade apprehension by members of the police force. His death is therefore a death in custody within the meaning of that expression in the Coroners Act 2003 and this Inquest was held as required by section 21(1)(a) of that Act.

1 Exhibit C2a

2. Investigating officer’s report 2.1. The investigating officer in this matter was Chief Inspector Gray. Her report2 is extremely comprehensive and thorough. It represents a textbook example of what a report of this nature should be. Chief Inspector Gray has left no stone unturned in her examination of the circumstances surrounding Mr Quinn’s death. Her investigation is frank and fearless and she has made certain criticisms of the handling of the matter by SAPOL without attempting to skirt or conceal any shortcoming on the part of that organisation, of which she is a senior member. I commend Chief Inspector Gray for the excellence of her investigation. It is a benchmark against which all investigations into deaths in police custody may be judged.

2.2. I have said that Chief Inspector Gray made certain criticisms of SAPOL’s actions or those of some of its officers in the lead up to Mr Quinn’s death. I can say at the outset that in my assessment none of the shortcomings identified by Chief Inspector Gray were of such a nature that they contributed to Mr Quinn’s death. If the shortcomings identified by Chief Inspector Gray had not occurred, it is my opinion that Mr Quinn’s death would not have been avoided. Chief Inspector Gray very properly did not seek to trivialise or understate the shortcomings she identified. However, I have reached the conclusion that to the extent those matters identified by her could be described as shortcomings, they were not of a serious nature, and although worthy of mention, did not affect the outcome.

3. Mr Quinn’s background 3.1. Mr Quinn was born in Adelaide in September 1978. He was the youngest of three children. His father left the family before Mr Quinn was born. Mr Quinn was brought up by his mother, a stepfather and two siblings. When he was 3 years of age a half brother was born. By all accounts Mr Quinn enjoyed a close relationship with his mother, his siblings and his stepfather.

3.2. Mr Quinn enjoyed his early years at school and showed promise in sporting activities, particularly cricket. He won a literacy aware in Year 7 and attended Brahma Lodge and Salisbury North schools. Unfortunately when Mr Quinn was 12 he was involved in a serious accident in which he was hit by a motor vehicle. He sustained severe 2 Exhibit C148a

fractures to both legs which required extensive treatment and rehabilitation. As a result of these injuries he missed the entire year of schooling at the level of Year 8 and upon his return to school was nevertheless placed into Year 9.

3.3. For obvious reasons he struggled with his school work thereafter and finally left school to work in a factory. This employment experiment required him to be involved in heavy lifting but because of the injuries he had sustained in the accident, they were not suitable for him. He returned to school for a brief period but left again after having difficulty with his academic requirements. He finally left school without completing Year 10.

3.4. Mr Quinn’s mother made a statement in which she said that from the age of 13 or 14 Mr Quinn began displaying disorganised, odd and anxious behaviour. He was medically assessed and later prescribed antidepressant medication but this was not continued. He continued however to suffer from chronic anxiety which appeared to be worse when he started taking illicit substances. He started coming to the attention of police at approximately the age of 15 years. His criminal behaviour arose as a result of his consumption of illicit substances. He experimented with a range of different drugs but struggled mostly with amphetamines. At the height of his addiction to that drug he was using intravenously and on a daily basis.

3.5. Mr Quinn was admitted to mental health facilities frequently because of his drug taking which in turn increased his anxiety and disordered thoughts. Mr Quinn did respond well to structure, routine and discipline and it was observed by members of the family that he was more settled when in custody. By contrast when in the community, particularly after spending some time in gaol, he was observed to struggle with the demands of work and independent living. As a result he would fall into a pattern of substance abuse and criminal activity. Mr Quinn had a long term partner with whom he had two children and they were certainly features of his life that had a stabilising influence upon him.

3.6. Mr Quinn answered charges in the Youth Court from the age of 15, at first for minor matters and then more serious offences. He received a suspended sentence obligation in 1995 and spent 3 months in detention in 1996 for breaching that obligation.

3.7. Mr Quinn’s first appearance in the District Court was in 1997 at the age of 18 when he was sentenced to 2 years imprisonment for receiving stolen goods. That sentence

was suspended upon him entering into a good behaviour bond. In March 1999 Mr Quinn was sentenced to 5 years and 2 months imprisonment for burglary, driving offences and breaching the good behaviour bond that he had entered into 2 years earlier. His non-parole period was set at 15 months. While in custody serving this sentence he was brought before the Elizabeth Magistrates Court for further sentencing for two counts of serious criminal trespass, illegal use and property damage. He received a head sentence of 4 years and 11 months and his existing non-parole period was extended by 5 months and 7 days.

3.8. In November 2003 Mr Quinn was again sentenced in the District Court for the charges of robbery and serious criminal trespass. He was sentenced to 4 years and 11 months imprisonment with a non-parole period of 3 years. While in custody serving that sentence he was brought before the Mount Barker Magistrates Court for serious and minor indictable offences the sentences for which added to his head sentence but did not affect his non-parole period.

3.9. Finally, in November 2008 Mr Quinn was sentenced in the Elizabeth Magistrates Court for two counts of serious criminal trespass, three counts of theft, resist arrest and possess article to commit offence. He received a head sentence of 5 years and 8 months and a non-parole period of 18 months. Mr Quinn was released on parole on 25 May 2010 and placed under the supervision of the Elizabeth Community Corrections office.

4. Mr Quinn’s record as a parolee 4.1. Mr Quinn’s parole address was the home of his mother and stepfather at Brahma Lodge. He was required, among other conditions of parole, to report once a week to his Community Corrections officer and to submit to random urinalysis testing. On 14 July 2010 Mr Quinn reported for supervision and he was required to submit to a urinalysis test. The result for that test was returned the following day. It revealed a positive result for cannabis. On 23 July 2010 when Mr Quinn next attended for supervision by his parole officer the results of the urinalysis were discussed. Mr Quinn admitted that he had smoked marijuana and that he was disappointed with himself. He was directed by his Community Corrections officer to attend the Drug and Alcohol Service South Australia. He already had an appointment for that purpose on 21 July 2010 which he had not kept and he informed his parole officer that he had

rescheduled the appointment for August. The Community Corrections officer wrote to the Parole Board informing the Board of the positive urinalysis and recommending that Mr Quinn receive a warning letter and that he be drug tested again in the near future and that his appointment with the Drug and Alcohol Service South Australia be monitored for attendance.

4.2. On 28 July 2010 Mr Quinn was scheduled to report for supervision at the Elizabeth Community Corrections office. He contacted the office prior to the appointment to inform them that he would not be attending as he did not have transportation. An alternative reporting time was arranged for 30 July 2010. However he did not attend on that day either and did not make contact with his officer to explain why. The Community Corrections officer then faxed an urgent minute to the Parole Board notifying of his failure to attend for supervision and referring to the previous minute concerning his positive urinalysis. The Community Corrections officer was concerned that Mr Quinn was commencing a pattern of avoidance behaviour and she recommended that the Board consider issuing a warrant.

4.3. Accordingly, the deputy presiding member of the Parole Board applied for a warrant on 3 August 2010. In the meantime Mr Quinn attended the Elizabeth Community Corrections office on 4 August 2010 and was asked to provide a urine sample to test for drugs. Mr Quinn stated that he was unable to provide a sample and after 1½ hours in the alcohol and drug monitoring unit he left without providing a sample. This was regarded as a refusal and was documented as such. This event was also the subject of a minute by Mr Quinn’s Community Corrections officer to the Parole Board requesting that a warrant be issued. As I have already said, a warrant had already been issued for Mr Quinn’s arrest as a result of the Parole Board’s application on 3 August 2010. The warrant was issued on 5 August 2010 and Police Corrections were notified on that day.

4.4. Mr Quinn’s warrant was assessed by the Police Corrections section and his case was classified as medium risk to the safety of the community at large. On 8 August 2010 the Elizabeth Uniform Tactical Team was given the responsibility for locating Mr Quinn and arresting him on the warrant. As a result members of that team attended many addresses attempting to locate Mr Quinn, including the addresses of family members. Senior Sergeant First Class McCue of that team gave evidence at the

Inquest. In his statement3 he said that ongoing attempts were made to locate Mr Quinn by various members of the Uniform Tactical Team. Mr Quinn’s family members were not responsive to attempts being made by police to locate Mr Quinn and in fact they threatened police with legal action for persistently attending the Brahma Lodge address. On 8 August 2010 Constable Pike reported an attendance at the Brahma Lodge address. He reported speaking to Mr Quinn’s stepfather who would not allow a search of the premises quoting a recent family death as the reason.

He said that Mr Quinn still resided at the address and slept there the night before and that Mr Quinn was aware that the police wanted to speak to him. Mr Quinn’s stepfather said he would get Mr Quinn to call or attend at the Elizabeth police station.

4.5. Mr Quinn’s stepfather telephoned Mr Quinn and advised him that the police had visited and were wanting to speak to him. He initially agreed to come home at 9pm to see the police but then he phoned his stepfather back and said that he would not be coming home to meet the police and to let them know. He said that he wanted to speak to his parole officer prior to speaking with the police4.

4.6. On 11 August 2010 Constable Pike reported a further attendance at the Brahma Lodge address. He said that he spoke with Mr Quinn’s stepfather who was cooperative but not happy. It was Constable Pike’s assessment that Mr Quinn’s stepfather was lying about his knowledge of Mr Quinn’s whereabouts. The house was searched and Mr Quinn’s keys and lighter were located in his bedroom. The backyard was searched and it was noted that there was a ladder placed at the back fence offering easy access to the adjoining backyard. There was no apparent reason for the ladder to be there.

The yard at the rear of the Quinn residence was searched thoroughly but Mr Quinn was not located.

4.7. Police made further attendances at the Brahma Lodge address on 4 August, 15 August and 18 August 2010 without locating Mr Quinn.

4.8. On 12 August 2010 Mr Quinn sent a text message to his sister saying that he was ‘a bit paranoid about visiting in case cops are there’. He said he would hand himself in once he was aware of how a sick relative was going to be5. On 19 August 2010 Sergeant McCue sent an email to the Police Corrections section to advise of the 3 Exhibit C40a 4 Statement of Tracey Quinn, Exhibit C28a 5 Exhibit C28a

difficulties in locating Mr Quinn. On 20 August 2010 police were advised by Mr Quinn’s parents that he had moved to a new address and they had no idea where he was. On this occasion all Mr Quinn’s possessions had been removed from the house.

4.9. On 25 August 2010 Jason Quinn, Mr Quinn’s brother, advised the police that Mr Quinn was aware that the police were looking for him for his parole warrant but was also of the belief that they were wanting him because his DNA had appeared at the scene of a robbery. Jason Quinn said that Mr Quinn was going to move to Victoria6.

On 26 August 2010 police attended and searched premises as Salisbury Park looking for Mr Quinn. They spoke with Tracey Quinn, Mr Quinn’s sister. She informed that Mr Quinn was keeping in touch with the family as her cousin was in the Royal Adelaide Hospital but Mr Quinn had stopped visiting since he had become aware that police were looking for him. On that day police attended and searched premises at West Richmond looking for Mr Quinn. The occupants stated they knew a person by the name of Paul but denied knowing his surname or whereabouts. They said he was last there a few days previously but did not know when he would be back.

4.10. On 29 August 2010 police attended and searched premises at Parafield Gardens but were unable to locate Mr Quinn.

4.11. Sergeant McCue said that after 29 August 2010 no other inquires were conducted by the Elizabeth Uniform Tactical Team to locate Mr Quinn given that they had received information that he was travelling to Victoria and that all the indications were that he was no longer in or visiting the Elizabeth Local Service Area7.

4.12. Police Corrections section records indicate that the parole warrant was reviewed on 16, 26 and 31 August 2010 and 13 and 18 September 2010. On each occasion the warrant was reviewed, the police warrant information network was updated with the code UNKN meaning that inquiries were exhausted and his whereabouts were unknown8.

4.13. On 3 September 2010 the Police Corrections section forwarded a weekly circular referring to Mr Quinn and highlighting the fact that he had an outstanding warrant and was avoiding recapture. The circular was uploaded on the police intranet and then forwarded to all intelligence areas for dissemination.

6 Exhibit C148a 7 Statement of Sergeant McCue, Exhibit C40a 8 Exhibit C148a

4.14. In my opinion Mr Quinn was actively attempting to evade apprehension9. In my view the efforts by police to execute the warrant were entirely reasonable and satisfactory given the circumstances they faced.

5. The Operation Decipher investigation 5.1. Operation Decipher was a police operation commenced as a result of a series of armed robberies that had occurred starting in late July 2010 and continuing over the next two months. The series consisted of robberies at the hotels mentioned in the following table on the dates appearing opposite them in that table.

Robbery Location Date Morphett Junction Hotel 29 July 2010 Oriental Hotel 4 August 2010 Brahma Lodge Hotel 18 August 2010 Seaton Hotel 20 August 2010 Largs Pier Hotel 24 August 2010 Aussie Inn Hotel 27 August 2010 Excelsior Hotel 28 August 2010 Racquets SA Club 31 August 2010 Woodville Hotel 2 September 2010

5.2. It is not necessary for the purposes of this finding to describe the series of armed robberies in greater detail other than to say there were certain features which appeared to connect them to the same offenders. On 30 August 2010 Detective Acting Sergeant Forrest created a person of interest document. One of the names placed upon that list by Detective Forrest was that of Paul Quinn. Detective Forrest included Mr Quinn’s name because he had a history of armed robbery offences and he had been released from prison earlier that year. Detective Forrest had also conducted checks on Mr Quinn which revealed that he was wanted on a Parole Board warrant and that the Elizabeth Local Service Area Uniform Tactical Team had made extensive inquiries to locate him without success. Apart from this there was no other information to suggest that Mr Quinn was involved in the series of robberies. Indeed, the Inquest heard that there was no evidence linking Mr Quinn to any of the robberies with the exception of the Woodville Hotel robbery following which a pair of black gloves was located a short distance from a burnt out Holden sedan which appeared to 9 Exhibit C28a - Furthermore the presence of the ladder in the backyard of the premises at Brahma Lodge indicated that Mr Quinn had prepared a ready means of escape in the event that police attended the house whilst he was there

have been involved in the robbery. Mr Quinn’s DNA was subsequently matched to a tape lift from those gloves10.

5.3. On 3 September 2010 police received further information involving three further persons believed to have had an involvement with the armed robbery at the Aussie Inn. One of those persons was William Strugnell.

5.4. On 4 September 2010 Detective Forrest sent an email to Senior Sergeant Eyre and Sergeant Watkins of the STAR Group. The email provided a synopsis of Operation Decipher, an intelligence summary sheet and the current status of activities being conducted by the Operation. Its purpose was to ensure that STAR Group members would have a sufficient knowledge to respond to a related incident if required11.

Detective Sergeant Hilliard gave evidence at the Inquest. She was responsible for supervising the allocation, administration and investigation of the Operation Decipher armed robbery offences. Detective Hilliard made changes to rostering to allow greater response capacity to Tier 2 robberies. She created a 24 hour on-call roster and made sure a database of personnel was kept. Each robbery was recorded in a case management system and linked within the system of Operation Decipher12.

Detectives Hilliard and Forrest and Detective Sergeant Grant continued to manage the investigation. They disseminated intelligence summaries to intelligence areas on 30 August, 1 September, 3 September, 8 September and 24 September 2010. Trigger plans were created and forwarded on 5 September, 9 September, 10 September, 17 September and 18 September 2010.

5.5. A Trigger Plan is a document intended to assist in the effective deployment of resources to specific locations of interest following a robbery believed to be connected with a crime series under investigation. Chief Inspector Dunstan gave evidence that a Trigger Plan is designed to direct general duty patrols or police officers not involved in a particular investigation to respond rapidly in response to an event relating to that investigation by attending at predetermined locations which are determined according to available intelligence13.

5.6. On 11 September 2010 Detective Grant of Operation Decipher became aware that information had been received the previous day that William Strugnell was in 10 Exhibit C148a, Miscellaneous Document 11 11 Exhibit C158 12 Transcript, pages 152-153, Exhibit C159, page 3 13 Transcript, page 321

possession of two sawn-off shotguns and had been involved in a number of armed robberies involving a shotgun14. At that point no information available to Operation Decipher pointed to the involvement of Mr Quinn in the armed robberies15.

5.7. On 14 September 2010 Detective Hilliard gave a thorough briefing to Inspectors Dunstan and Jenkins and other members about Operation Decipher. William Strugnell was identified as a suspect and covert strategies were developed. Detective Hilliard said that because William Strugnell was known to engage police in high speed pursuits and was thought to be armed with a shotgun and was a known drug user, it was decided that there would be no attempt to stop him while he was on the road but that surveillance would be used to locate a potential address for him where a cordon and call could be conducted16.

5.8. A cordon and call means that police would cordon off particular premises where a person was known to be located and would then make contact either by telephone or loud speaker with the occupant of the premises with a view to negotiating their surrender.

5.9. Inspector Dunstan said that based on the assessment provided by Detective Hilliard, he directed that any contact with William Strugnell would be treated as ‘high risk’.

He directed that no attempt would be made to stop William Strugnell while he was in a vehicle due to the risks involved17.

6. Friday 17 September 2010 6.1. In the days immediately prior to Friday 17 September 2010 the number plates belonging to a Toyota Yaris sedan bearing the numbers S102-ADK were stolen from that sedan. This theft was reported to police on 17 September 2010. Between the hours of 12:30am and 8:30am that same day a silver 1996 Toyota Aristo sedan was stolen from a home at Woodforde. The car was reported stolen the same day18. A Toyota Aristo is a model that was not generally available in Australia. The vehicle in question would have been imported from Japan. As a consequence, subsequent sightings of this vehicle were reported by various witnesses to be sightings of a 14 Statement of Detective Grant, Exhibit C41a 15 Exhibit C41a 16 Exhibit C159 17 Exhibit C163 18 Exhibit C7a

Toyota Soarer (or similar). I am entirely satisfied that all of the sightings by the various witnesses to which I will be making reference hereafter, were sightings of the stolen Toyota Aristo. I will refer to it as the Toyota Aristo despite the fact that original references in witness statements wrongly name it as a Soarer. The confusion is explained by the similarity in appearance between the two models and the fact that a Soarer was a model commonly available in Australia.

6.2. At about 4:15pm on 17 September 2010 Detective Forrest of Operation Decipher was advised that a silver Toyota Aristo bearing stolen plates S102-ADK was observed at an address associated with William Strugnell. He was also aware of some other sightings of the same vehicle. He believed that Police Communications (Comcen) had been contacted and had advised all patrols of the details of the vehicle and that William Strugnell may possibly be in the vehicle in possession of firearms and that any activity relating to the vehicle would be high risk19. At 5:37pm that day Detective Grant contacted Comcen and requested that the operator send out an all patrols advice to keep a lookout for the silver Toyota Aristo S102-ADK and another vehicle suspected as part of Operation Decipher. Detective Grant advised that William Strugnell could be in the vehicle and stated that he was not wanted for anything but he may be armed and so if the vehicle was stopped, caution should be used. Detective Grant also contacted STAR Group and spoke with Inspector Wall. He advised Inspector Wall that William Strugnell had become a strong suspect for the robbery series and was believed to be in possession of firearms. Inspector Wall requested the information be emailed to him. Detective Hilliard sent him copies of the Operation Decipher summary and the Trigger Plan. That same afternoon an updated Operation Decipher Trigger Plan was emailed to the Communications Branch.

6.3. On 16 and 17 September 2010 Detective Sergeant Patterson of the Investigation Support Branch was conducting plain clothes surveillance duties with other police officers in relation to William Strugnell, presumably at the instigation of Operation Decipher20. At about 3pm on 17 September 2010, while conducting observations outside 14 Kerry Avenue, Seaton, an address associated with William Strugnell, Detective Patterson observed the Toyota Aristo bearing plates S102-ADK park directly in front of the premises. He observed two men alight from the vehicle and 19 Exhibit C148 20 Exhibit C161

walk to the front door of that address. About 25 minutes later the two men left those premises and returned to the Toyota Aristo. Detective Patterson and other members of his unit commenced to follow the vehicle covertly.

6.4. At 9:25pm that evening the Toyota was seen by the surveillance team at a BP service station at Wingfield. The two occupants of the vehicle were subsequently identified from CCTV footage at that service station as William Strugnell and Mr Quinn.

6.5. At 10:01pm the Toyota was observed to drive into the driveway of the Royal Oak Hotel, North Adelaide. It was then seen shortly after to exit those premises and was followed around North Adelaide until at 10:15pm police lost sight of it in the vicinity of Medindie. At about that time an armed robbery was committed at the Royal Oak Hotel. A male suspect wearing a balaclava had entered the gaming room armed with a sawn-off double barrel shotgun and had demanded money from staff. Detective Brevet Sergeant Leaker from Operation Decipher, on becoming aware of the robbery at the Royal Oak Hotel, notified all patrols via police radio that the likely vehicle involved was a ‘Soarer bearing stolen number plates S102-ADK’. He requested an all patrols advice by Comcen that if that vehicle were located it was not to be engaged in a high speed pursuit and furthermore that the occupants may be armed with a firearm.

Patrols should contact Operation Decipher if the vehicle was sighted. The instruction was that patrols should not pursue the vehicle but should provide wide cordons while resources such as STAR Group and Polair would be deployed to effect the safe arrest of the occupants of the vehicle21. Detective Hilliard then contacted Comcen and instigated the Operation Decipher Trigger Plan and requested that the police helicopter (Polair) be deployed. Detective Hilliard also requested that Comcen arrange for the STAR Force to be deployed ‘for a high risk arrest’22.

7. Conflicting opinions of Senior Sergeant Eichner and Detective Patterson 7.1. On the evening of 17 September 2010 Detective Patterson’s team had the Toyota Aristo under covert surveillance for much of the evening. After the robbery at the Royal Oak Hotel, the STAR Force were deployed and the Polair helicopter was 21 Exhibit C51a 22 Exhibit C148a

airborne. Detective Patterson expressed the opinion in his statement23 that an opportunity existed for the STAR Operations Team to safely apprehend the occupants of the Toyota Aristo but that the opportunity was not taken up by STAR Operations.

Sergeant Eichner on the other hand said that the information STAR Operations was receiving from the covert surveillance team was not sufficiently specific for his team to conduct a safe arrest. In the end, Detective Patterson acknowledged that the final decision properly rested with Sergeant Eichner. Clearly this involves a matter of judgment by those who are on the spot. I suppose it might be suggested that if STAR Operations had managed to effect the safe arrest on the evening of 17 September 2010 then the tragic event of Mr Quinn’s death on 19 September 2010 might have been avoided. However, the evidence shows that Sergeant Eichner’s approach was perfectly justifiable. Had he directed his officers to act when Detective Patterson suggests he could have done so, the result may have been even more unfortunate than the result on the Sunday night. The opportunity of which Detective Patterson spoke would have required an arrest to occur in a public place at which innocent third parties may have been affected, and possibly injured or worse. I make no criticism of Detective Patterson for expressing his views in a forthright and honest manner. It is in SAPOL’s interests that senior officers be encouraged to express opinions in the aftermath of events such as these. In that manner, opportunities for improvement can be considered and implemented if appropriate.

8. Friday 17 September and Saturday 18 September 2010 8.1. In the result, the covert surveillance was compromised by the presence of the Polair helicopter which was flying low and the occupants of the Toyota Aristo became aware of the probability that they were being followed. The vehicle was last seen by SAPOL members in the area of Coglin Street, Hindmarsh sometime just before midnight on 17 September 2010. As I have previously mentioned, it was established subsequently from the CCTV footage at the BP service station at Wingfield that Mr Quinn was one of the occupants of the vehicle on the night of 17 September 201024.

8.2. At approximately 9:15am on Saturday 18 September 2010, Detectives from Operation Decipher attended carparks in the vicinity of the Stamford Plaza Hotel, North Terrace, Adelaide in an attempt to locate the Toyota Aristo. Enquiries were also conducted at 23 Exhibit C161 24 Exhibit C148a

the hotel itself to establish if William Strugnell was staying there. At approximately 11:49am that morning details of the Toyota Aristo, including the stolen registration number, were provided to Comcen for the delivery of an all patrols message. The information included the possible involvement of the Royal Oak Hotel robbery. All patrols were warned to use caution if sighting or locating the vehicle and to contact Operation Decipher immediately should the vehicle be sighted. At 11:55am that day Detective Forrest received information that William Strugnell was at an address at Seaton. At approximately 2:35pm Operation Decipher members and STAR Group members positioned themselves to conduct a high risk cordon and call operation at Carey Avenue, Seaton. However, by that time information was received that William Strugnell was no longer present at the premises. A decision was made to enter and search the premises but nothing was located. As a result of discussions between Inspectors Dunstan and Jenkins and Detective Forrest, Detective Forrest contacted SAPOL Records Response Unit and ensured that the registration number of the stolen Toyota Aristo and the stolen number plates S102-ADK were flagged with appropriate information. This included the fact that William Strugnell may possibly be in the vehicle and if approached was suspected of being in possession of firearms. Detective Forrest left instructions to contact Operation Decipher in the event of contact with the vehicle or a vehicle bearing those number plates25. Detective Forrest then updated the Operation Counteract Trigger Plan and disseminated it to the Communications Branch at 6:51pm that day. The Trigger Plan contained information relating to William Strugnell, details of two vehicles of interest including the Toyota Aristo and four addresses of interest. The addresses were listed to assist in the deployment of police resources following any robbery suspected to be linked to the suspects.

8.3. That evening a human source provided information to police that the person who was committing the armed robberies was called ‘Paul’. Detective Forrest concluded that Paul could possibly be Paul Quinn. That possibility was put to the human source who agreed. No further information was able to be obtained except that the firearm may be at Campbelltown26. Detective Forrest was satisfied that all police checks possible had been done. There were no Operation Decipher members rostered for work on the following day, Sunday 19 September 2010 and Detective Forrest resolved that further enquiries to check the veracity of the information about Mr Quinn could be left for Monday 20 September 2010.

25 Exhibit C148a 26 Exhibit C148a

9. Events of Sunday 19 September 2010 9.1. As I have mentioned, on 19 September 2010 no Operation Decipher personnel were rostered on shift. Inspector Dunstan said this was because of the amount of resources that had been committed to Operation Decipher in the preceding 72 hours. The result was that no member of Operation Decipher was available to be rostered for duty on Sunday 19 September 2010. Detective Hilliard was performing the role of the on-call contact officer for that weekend in relation to Operation Decipher27. As a result there were no covert resources available on 19 September 2010 either. The unavailability of Operation Decipher members on 19 September 2010 had two consequences. One was that the information relating to Mr Quinn obtained the previous evening was not pursued that day. The second was that when the Toyota Aristo was detected by police and involved in police pursuits later that day, no Operation Decipher members were on duty at the commencement of that event. I leave the second issue until later in this finding. As to the first, my opinion is that it is unlikely that any attempt to locate Mr Quinn on 19 September 2010 would have been successful given that enquiries had already been made by Elizabeth Uniform Tactical Team members in an effort to locate him.

9.2. Between 11:10am and 11:20am that Sunday the Toyota Aristo was involved in a theft of petrol from a service station on Magill Road.

9.3. At 3pm on 19 September 2010 Sergeant Beattie of Eastern Adelaide Patrols provided a briefing to his team members about the robbery at the Royal Oak Hotel on the previous Friday night. He advised his team members that William Strugnell was a suspect for that robbery and was to be treated as armed and dangerous. At approximately 3:10pm Intelligence Officer Senior Constable Martin gave patrols from Grenfell Street, Hindley Street and Norwood police stations, Crime Scene Investigators, Criminal Investigation Branch and bicycle patrols the daily intelligence briefing. No mention was made of the armed robbery at the Royal Oak Hotel.

However, Senior Constable Martin informed the members present that he was expecting a Trigger Plan to be provided by Operation Decipher in relation to that robbery. However he had not received it at that time. At that briefing Detective 27 Exhibit C163

Sergeant Pratt of Eastern Adelaide Criminal Intelligence Branch (CIB) gave a briefing as to his knowledge of the events.

9.4. At approximately 5:30pm Detective Pratt conducted a briefing at the office of Eastern Adelaide CIB with supervisors from Eastern Adelaide Local Service Area, afternoon shift CIB members and crime scene investigators. Acting Senior Sergeant Phillips, the Local Service Area Shift Supervisor, Acting Sergeant Medhurst, Sergeant Beattie, Sergeant Michael and Senior Constable First Class Easton were among those who attended this briefing. Detective Pratt was aware of the armed robbery at the Royal Oak Hotel on 17 September 2010 and that William Strugnell was thought to be involved. Detective Pratt informed those present that William Strugnell was to be considered armed and dangerous and extreme caution was to be used if he was sighted. Detective Pratt supplied details of the suspect vehicle and colour photographs of William Strugnell to be disseminated amongst all patrol staff. As part of the briefing a plan was formulated in the event further armed robberies were committed by William Strugnell during that shift. The plan was to the effect that patrols were to pay attention to all licensed premises in an effort to have a highly visible police presence and deter any further armed robberies in the Eastern Adelaide Local Service Area. As part of the plan Senior Sergeant Phillips was to assume the role of Forward Commander from Norwood Patrol Base if an incident took place.

Senior Sergeant Phillips emphasised the General Orders related to high risk driving and the need to terminate the pursuit if the General Order required that to occur. It was also planned that cordons would be set up on major roads and intersections in an attempt to sight the vehicle and contain it while trying to organise the police helicopter to assist.

9.5. At approximately 8:18pm the Toyota Aristo was seen in the vicinity of William Street and Charles Street, Norwood. Sergeant Medhurst became aware of this and directed a patrol to check the vicinity of 1 Boskenna Avenue, Norwood. This was one of the addresses referred to in the Trigger Plan. Senior Constable Gilchrest and Probationary Constable Griffiths were driving an unmarked police vehicle at this time. They were requested by Senior Sergeant Phillips to drive along Boskenna Avenue to see if they could sight the Toyota Aristo. They stopped their vehicle on Little Flinders Street to put on their ballistic vests given the information they had received that the driver of the suspect vehicle may be a high risk person and in

possession of a firearm. They drove onto Boskenna Avenue to a laneway located on the northern side and into a carpark area behind a two storey building. As they drove northwest in the carpark they observed a dark colour car parked at the southern end of the carpark. They then heard loud revving noises and observed the Toyota Aristo accelerate at speed towards them. They reversed their vehicle to avoid the Toyota and the Toyota accelerated through the carpark colliding with a fence on the eastern side of it and then left. They turned to follow the vehicle but lost sight of it. At approximately 8:20pm Sergeant Leaker of Operation Decipher received a call that the Toyota Aristo had been sighted by Adelaide Patrols. Sergeant Leaker asked to be kept informed. Sergeant Leaker then advised Detective Hilliard of the information.

At about 8:30pm a police vehicle began pursuing the Toyota Aristo at a speed of 91 kilometres per hour on Wakefield Street, Kent Town. The Toyota Aristo then turned onto Dequetteville Terrace to travel northwest. The police vehicle gave chase with its emergency equipment activated and estimated the speed of the Toyota to be in excess of 120 kilometres per hour. After about 10 seconds the officers were advised to terminate the pursuit. At 8:30pm Sergeant Medhurst had heard on police communications that the Toyota Aristo was travelling at high speed on Dequetteville Terrace. He directed via Comcen that the vehicle not be pursued. As previously organised in the briefing with Detective Pratt, Senior Sergeant Phillips advised that he was taking on the role of Incident Controller at 8:33pm. Senior Sergeant Phillips, Sergeant Medhurst and Sergeant Beattie then coordinated the existing police patrols and requested further assistance. Senior Sergeant Phillips advised Inspector Teakle, the Acting Eastern Adelaide Operations Inspectors of the incident and he advised that he would take over command on his arrival. Senior Sergeant Phillips ensured that all members put on ballistic vests including members in the adjoining Local Service Areas of Holden Hill and Western Adelaide. He also requested that Polair be informed and dog patrols as well. Senior Sergeant Phillips’ intention at that time was to use static patrols and the CCTV cameras located through the city to locate the vehicle. He contemplated that Polair might follow the vehicle to a location, ideally a residential address, and then employ cordon and control tactics to arrest the accused safely and without incident.

9.6. At approximately 8:30pm Senior Sergeant Spencer from STAR Group had a telephone conversation with Sergeant Forrester of Police Communications in relation to the Toyota Aristo and what was occurring at that time. As a result of that

conversation Senior Sergeant Spencer tasked Brevet Sergeants Thorn and Rogers to commence duties with the police helicopter. He also tasked STAR Group members Senior Sergeant Girardi, Brevet Sergeants Moir and Garlik to assist general duties police to search for the vehicle and the occupants. Sergeants Thorn and Rogers left the STAR Group Patrol Base to conduct a 30 minute flight in Polair to search for a silver Toyota sedan, registration number S102-ADK. Sergeant Rogers was aware that this vehicle was wanted in relation to a series of armed robberies and that a person committing these robberies was armed with a shotgun when they were committed.

Senior Sergeant Girardi of STAR Group had been monitoring the Eastern Adelaide radio channel and was aware of the pursuits involving a Toyota Aristo. He was aware of the fact that police had been trying to locate the vehicle over the past few days and that it was wanted in connection with armed robberies at hotels. He was also aware that suspects were armed with a shotgun. He spoke with STAR Operations Manager Senior Sergeant Spencer and advised that he was planning to go out and assist patrols in company with Sergeants Moir and Garlik. The three STAR Group members travelled north on Marion Road. Sergeant Moir was driving, Senior Sergeant Girardi was in the front left passenger seat and Sergeant Garlik was in the rear left passenger seat. The three STAR Group members were armed with a general duties patrol rig which included hand guns (Glock 17), a spare magazine, capsicum spray, baton and handcuffs. Sergeant Garlik was also armed with a Bushmaster rifle and had placed a Tazer in the vehicle.

9.7. At 8:49pm Inspector Teakle commenced as Forward Commander with Sergeant Medhurst becoming the recorder and commencing an operations log. Inspector Teakle commenced to manage patrol resources using a large laminated map. At 8:54pm the police helicopter was airborne. At approximately 8:58pm there was a further sighting of the Toyota Aristo. It was travelling southwest on Anzac Highway approaching the intersection of Marion Road. The Toyota was seen to turn against a red arrow into Marion Road and travel north. On receiving this information Inspector Teakle deployed patrols to cordon points on the western side of the central business district and alerted the police helicopter. At 9:06pm a police patrol in Richmond observed the Toyota Aristo on Brooker Avenue in that suburb. The patrol activated its emergency equipment and advised Comcen that it was engaging in a high speed pursuit. They followed the Toyota but terminated the pursuit at the intersection of

Bagot Avenue and Henley Beach Road, Mile End when they lost sight of it. The police helicopter had been unable to travel to that vicinity at the time due to air traffic.

9.8. In the meantime Senior Constable Hastie heard via police radio that the Adelaide Senior Sergeant had authorised the use of road spikes. He attended at the intersection of Henley Beach Road and South Road, Mile End. He prepared to deploy road spikes. He observed the Toyota approach his location and turn into the slip lane to travel north on South Road. Senior Constable Hastie moved forward and deployed the spikes onto South Road in the northbound carriageway. He estimated that the Toyota was travelling at 20 to 30 kilometres per hour at the time the front passenger side wheel of the Toyota made contact with the road spikes. The Toyota continued to drive north before crossing onto the southbound carriageway of South Road and then turning right. At about 9:10pm Senior Constable Hastie advised all patrols via police radio that the Toyota had successfully been spiked.

9.9. At about 9:15pm a police patrol observed the Toyota Aristo in the rear carpark of the Squatters Arms Hotel near the corner of George Street and Port Road, Thebarton.

They advised via police radio that they had located the Toyota Aristo but on doing so it left the carpark of the Squatters Arms Hotel at high speed. They saw it drive through a red light on Port Road and drive towards the city in a southeasterly direction along Port Road. The Toyota was at this time pursued by at least two police vehicles, including the STAR Group vehicle containing Senior Sergeant Girardi, Sergeant Moir and Sergeant Garlik. These vehicles followed the Toyota Aristo for 200 or 300 metres with other police vehicles near them and then deemed that it was too dangerous to keep following and backed off. The Toyota Aristo had moved onto the wrong side of the road at that stage and was in the path of oncoming vehicles. It was then seen by police patrols including patrols that were static at the intersections of West Terrace, Adelaide and streets leading into the CBD from West Terrace to travel south along West Terrace. The Toyota was on the wrong side of the road travelling on the northbound carriageway. At one point the Toyota moved back onto the southbound carriageway and continued travelling south. However, by the time the Toyota Aristo reached the intersection of West Terrace and Wright Street, it was again travelling on the wrong side of the road.

9.10. The police officers travelling in the Polair helicopter first sighted the Toyota Aristo travelling on the incorrect side of Port Road heading towards Adelaide. The officers onboard Polair then communicated over police radio that they had observations on the vehicle and requested all police to stand out of the chase. STAR Group member Sergeant Thorn observed the Toyota travelling at high speed with its lights off along West Terrace. He observed the vehicle narrowly missing oncoming vehicles as it passed them. At the intersection of West Terrace and Anzac Highway the Toyota Aristo changed back to the correct side of the road and travelled in a southwesterly direction along Anzac Highway.

9.11. During this period the STAR Group members, Senior Sergeant Girardi, Sergeant Moir and Sergeant Garlik, in their vehicle were following the Toyota Aristo from a distance and were watching the police helicopter’s direction of travel. Sergeant Moir subsequently said: 'I was heading down Anzac Highway, I was ah we were made aware that suspect vehicle had gone behind Le Cornu, ah I turned left off Anzac Highway before South Road and at the direction of ah the passengers in the car were telling me which way to go, I was just following side streets.' 28 The STAR Group vehicle drove past the intersection of Leah Street and Anzac Highway and turned left into Berkley Street and then into Hillsley Street. They heard over the radio that the Toyota Aristo had stopped at East Terrace at the tram crossing29. The STAR Group vehicle then turned into Everard Terrace and turned out into Leah Street. Sergeant Garlik stated that ‘eventually we popped out on Leah Street, pretty much behind the vehicle’30.

9.12. By this time the Toyota Aristo had stopped in a southerly direction of travel on Leah Street, Forestville behind a car which was itself stationary at the tram crossing which is governed by boom gates.

9.13. As the STAR Group vehicle, which was a Toyota Landcruiser, travelled south on Leah Street towards the tram crossing, the Toyota Aristo performed a U-turn in order to travel north in the opposite direction from the Landcruiser. At that point the STAR Group Landcruiser crossed onto the incorrect side of the road and collided with the front right side of the Toyota Aristo causing it to stop.

28 Exhibit C167 29 This was actually a reference to Leah Street 30 Exhibit C166

10. The shooting of Paul James Quinn 10.1. Sergeant Garlik exited the Landcruiser wearing a bullet proof vest that he had put on earlier. He was holding his rifle and moved along the back of the STAR Group vehicle. He could not see inside the Toyota Aristo and moved across in front of it towards the passenger side. As he got out of the glare of the Toyota Aristo’s headlights he could clearly see a man holding a sawn-off double barrel shotgun with both hands holding it at chest height above the height of the door seal. Sergeant Garlik pointed his rifle at the man and shouted ‘shotgun’ several times to alert Senior Sergeant Girardi and Sergeant Moir to the existence of a shotgun. Sergeant Garlik was concerned as he realised that he was on the opposite side of the Toyota Aristo to Senior Sergeant Girardi and Sergeant Moir and was potentially in their line of fire so he kept moving towards the rear of the Toyota Aristo31. Senior Sergeant Girardi also saw a man holding a gun. He described seeing the man in the vehicle reaching to his left and lifting up a sawn-off shotgun. Senior Sergeant Girardi said that the man took aim at all three of the STAR Group members and said: '… he’s almost gone into defensive mode um being quite prominent with his uhm pointing his weapon at all three of us … you know checking us all out.' 32

10.2. Sergeant Moir also saw the man holding the gun. He said that the man was extremely agitated, moving around and had a firearm in his hands. He said that he was pointing the firearm. The three STAR Group members were yelling out words to the effect of ‘drop the gun, police, don’t move’. Senior Sergeant Girardi was to the front left of the police Landcruiser using the engine block for cover and was aiming his Glock 17 handgun at Mr Quinn. Senior Sergeant Girardi made a decision not to shoot at the time as he believed a shot would be ineffective because he would be shooting through the side window or the windscreen of the car33. Sergeant Garlik was at the back of the Toyota Aristo and could still see the man holding the gun in both hands. He could see at that stage that the man was not looking at him so he moved towards the driver’s side window and punched the muzzle of his gun through that window, repeatedly saying ‘drop the gun’. Almost instantaneously the man went across the console into the front passenger side seat, opened the passenger door and sprinted away from the vehicle34.

31 Exhibit C166 32 Exhibit C165 33 Exhibit C166 34 Exhibit C166

10.3. Sergeant Garlik saw the man running while holding the shotgun in his right hand. He began chasing the man with the other STAR Group members who were yelling at the man to ‘drop the weapon and put his hands up’. Sergeant Garlik was on the left, Senior Sergeant Girardi in the middle and Sergeant Moir to the right. Senior Sergeant Girardi said that when chasing the man, the man turned around and pointed the weapon back at them. The STAR Group members were yelling ‘drop the gun’.

Senior Sergeant Girardi did not attempt to shoot the man while chasing him because he was confident that the man would not aim properly because he was sprinting35.

Sergeant Moir gave a similar account36. From Polair, Sergeant Rogers saw a person leave the Toyota Aristo from the passenger door and run in a westerly direction.

Sergeant Rogers also saw Senior Sergeant Girardi, Sergeant Garlik and Sergeant Moir run after the person. The police in the helicopter then saw the fugitive run towards a house property situated on the corner of Leah Street and Norman Terrace, which runs parallel to the tram line. The police in the helicopter saw the person climb over what appeared to be a fence at the front of that residence37. The officers in the helicopter concluded that the barrier was reasonably high because the person had to reach up and pull himself over. The occupants of the helicopter saw Senior Sergeant Girardi, Sergeant Garlik and Sergeant Moir run over to those premises. One of them ran to the western side of the premises and the other two to the eastern side.

10.4. What happened next is best described in the words of Sergeant Moir: 'A. Ah I was extremely concerned and I remember thinking at the time that I was concerned for the welfare of the people in the house and I ah continued to, to go towards him to ahm to in attempt to apprehend him.

… Q. And what happened next Dan?

A. I, I recall thinking I’ve given him enough time or he’s had enough time to continue jumping the fence and continue.

Q. Yes.

A. So I, I got to the fence, I jumped over, ah I stood myself up or, or held myself up over the fence comfortably, I looked and I looked down ah and saw him on the ground.

Q. Ah there’s a bit of light there, you, you.

A. Oh I clearly cos, yeah clearly saw him.

35 Exhibit C166 36 Exhibit C167 37 In fact the premises were situated at 68 Leah Street, Forestville

Q. Okay ahm whereabouts, just note on that little mud map, where that’s the ah fence line of course, whereabouts was he.

A. Down that here.

Q. So right by that little gate.

A. Yes.

Q. Okay and was he doing could you see what he’s doing and then.

A. He was, he on his back or his side but he was certainly looking towards me.

Q. On his back or his side looking towards you, could you see the firearm?

A. Yes.

Q. And what was he doing with that.

A. He, he’s, was still holding it comfortably.

Q. Yes.

A. As in having control of it and ah I, it was pointed in my direction.

Q. So you’re hanging on the top of the fence looking over.

A. Yes.

Q. He’s lying on the ground a shotgun pointing at you.

A. Yes.

Q. What happened next Dan?

A. I had flashes of, I want to go home, I want to see my kids, of I generally thought that my life was in danger and he’s gonna shoot me, ah so I, I fired a shot.

Q. Did he say anything to you.

A. No.

Q. Didn’t tell you piss off.

A. No.

Q. Did you say anything to him or you just fired.

A. Not at that stage.

Q. Okay ah.

A. Happened in a split second.

Q. Can you describe how you’re positioned on the fence to get the shot off. Ah how, how did that work out. Were you actually sitting on top of the fence or standing.

A. I wasn’t sitting I was holding myself up in, yep enough to look over to be comfortable to be balanced and to observe ah everything that was happening.

Q. You took aim.

A. I took aim.

Q. When you fired.

A. I fired.

Q. How many shots did you fire?

A. Two.

Q. Were they quick succession.

A. No I, I fired ah at that stage I recalled ah in a quick reassessment ah the danger felt like it was still there, fired again, ah and it felt like the danger had then stopped ah so then I’ve pulled myself back down on the other side of the fence.

Q. Is ah immediately you got down from the fence.' 38

10.5. Senior Sergeant Girardi heard the two gunshots and yelled ‘is everyone okay, is everyone alright’. Sergeant Garlik heard the two gunshots and was unsure if Sergeant Moir or the man with the shotgun had been shot so he ran to the house. He saw Sergeant Moir standing at the fence. He propped up on the top of the fence and saw the man lying on his back holding the shotgun on his chest and could see that the man was still breathing. Sergeant Garlik then kicked and hip and shouldered open the gate with Senior Sergeant Girardi to gain entry and approach the male. Sergeant Garlik took hold of the shotgun and threw it about a metre and a half away from the male.

Senior Sergeant Girardi then ran back to the STAR Group Landcruiser and advised Comcen that the male had been shot and that an ambulance was required urgently39.

11. Attempts to resuscitate Paul James Quinn 11.1. Sergeant Michael arrived at 68 Leah Street and entered the courtyard. He observed a male on the ground at that location and felt for a pulse on the man’s wrist but felt none. He then felt for a carotid pulse but none was present. Sergeant Garlik then heard Sergeant Michael say ‘no pulse, no pulse’. Sergeant Michael then started CPR assisted by Sergeant Moir, who was performing mouth to mouth resuscitation. Senior Sergeant Girardi maintained a hand over the bullet wound and applied direct pressure to prevent blood loss. They continued to perform CPR from about 9:21pm to about 9:35pm when the ambulance arrived40. A member of the South Australian Ambulance Service then arrived and examined Mr Quinn, but declared him life extinct41.

38 Exhibit C167, Question 160 and Questions 179 to 199 39 Exhibit C148a 40 Exhibit C167 41 Exhibit C148a

12. Ballistic examination 12.1. Brevet Sergeant Lawrence of Forensic Response Section undertook the ballistic examination of the scene and exhibits42. At about 11pm on the evening of the shooting Sergeant Lawrence attended at the scene and made observations of Mr Quinn and the scene. He observed two spent 9mm Luger cartridge cases which were located in the grass near Mr Quinn’s head. Also on the ground was a sawn-off Webley brand double barrel shotgun. Both hammers of the shotgun were in the cocked position and thus only required pressure on the trigger to cause the firearm to discharge. Each chamber was loaded with a live round of Winchester brand 12 gauge shotgun ammunition. Although the shot size is such as used for small game, it was the opinion of Sergeant Lawrence that at a distance of less than 10 metres, it was capable of causing a fatal wound to a human being. I am quite satisfied that the firing distance between Mr Quinn when lying down and Sergeant Moir when he appeared over the fence was much less than 10 metres, probably closer to 2 or 3 metres.

Further investigation showed that the Webley shotgun had been stolen along with four other firearms at a serious criminal trespass on a house at Noarlunga on 11 August 2010.

12.2. The firearms of Sergeant Moir, Senior Sergeant Girardi and Sergeant Garlik were later examined by Sergeant Lawrence. The examination of those weapons revealed that only one weapon had been shot which was Sergeant Moir’s Glock pistol. The examination revealed that the magazine had a capacity of 17 bullets (only 16 were loaded). Thirteen bullets remained in the magazine and one in the chamber. This indicated that two shots had been fired. The two spent 9mm Luger cartridge cases were examined and Sergeant Lawrence formed the opinion that the spent cases were fired from Sergeant Moir’s Glock pistol. The two bullets retrieved from the body of Mr Quinn were both spent 9mm copper jacket hollow point bullets with a lead core.

The overall rifling features on the two bullets were similar to the overall rifling features from Sergeant Moir’s Glock pistol, but could not be conclusively identified or eliminated43. I am satisfied taking into account the evidence of Sergeant Lawrence and all other evidence surrounding this matter that the bullets were indeed fired by Sergeant Moir using his Glock pistol.

42 Exhibit C137a 43 Exhibit C137a

13. Toxicology report 13.1. A blood sample was taken from Mr Quinn during his autopsy. It was subjected to a toxicological analysis and that revealed that Mr Quinn had consumed methyl amphetamine at levels consistent with illicit use. It was not possible to determine how much of that drug had originally been taken. No other drugs were detected.

14. Conclusions 14.1. I have previously mentioned that Chief Inspector Gray was critical of certain features of Operation Decipher.

14.2. Chief Inspector Gray noted that no Operation Decipher personnel were rostered on shift on 19 September 2010. The consequences of this were that the information concerning the involvement of Mr Quinn in the robbery at the Royal Oak Hotel was not pursued on the Sunday. The second consequence was that there was no covert surveillance measures in place on the Sunday. I have previously commented that I do not think that the delay in inquiries to identify and locate Mr Quinn would have been likely to have prevented the events of Sunday night. I think it unlikely that police would have been able to detect Mr Quinn that day given that he was actively avoiding police, and by the Sunday morning was well aware that police were on the lookout for him. Mr Quinn had been involved in the events of the previous Friday night and it became obvious later in that evening with the presence of the police helicopter that police were interested in his activities. Furthermore, the searches that took place on 18 September 2010 were likely to have come to his attention as well, putting him on a higher level of alert.

14.3. As to the absence of covert surveillance techniques, it would seem once again that these would be unlikely to have made any difference given the efforts to which Mr Quinn was likely on the Sunday morning to have been going to avoid detection. It is known from the statement provided by Mr Quinn’s sister, Tracey, that he attended at her home in the very early hours of the Sunday morning for a shower44. He made it plain that he was aware that he was being looked for by police and that he was avoiding detection. It was unlikely that covert surveillance would have been any more successful than overt surveillance that day.

44 Exhibit C28a

14.4. Chief Inspector Gray was critical that on the night of 19 September 2010 the incident was not declared to be high risk. On this question I accept the submissions of the Commissioner for Police. Inspector Teakle was the on-call officer of police for the Eastern Adelaide Local Service Area on that day. He said that at 8:23pm he was working in an office at Grenfell Street Patrol Base when he received a call from Senior Sergeant Phillips advising that patrols had possibly located the Toyota Aristo.

Inspector Teakle monitored police radio and noted that the Toyota had been sighted in Boskenna Street and subsequently Dequetteville Terrace. He noted that the pursuit had been terminated. After discussions with Senior Sergeant Phillips and Sergeant Medhurst at Norwood police station where Inspector Teakle had then attended, he commenced in the role as Forward Commander45. At 8:56pm Sergeant Medhurst commenced in the role as Recorder and made detailed records in relation to the incident.

14.5. Inspector Teakle then coordinated static and moving patrols, arranged for cordons on West Terrace, East Kintore Avenue and later in Thebarton. He ensured that observations on the suspect vehicle were maintained from a safe distance in order to relay information to the police helicopter when the latter was unable, by reason of air traffic in certain areas, to track the pursuit. Inspector Teakle was able to coordinate resources taking into account a situation which was highly dynamic. After he had taken the role as Forward Commander, radio transmissions were made directing patrols to maintain a safe distance from the Toyota Aristo. Inspector Teakle said that the intention of this was to maintain observations without provoking the driver into a high speed pursuit46. Radio directions were made requiring patrols going to the location to be ‘vested up’. Upon receiving advice from the police helicopter that it had observations on the Toyota Aristo, Inspector Teakle directed all patrols to back off and stay parallel so that they could try and box the Toyota in and use spikes if possible47. A further transmission was made directing that no cars were to be behind the suspect vehicle48.

14.6. Inspector Teakle gave evidence that terminating all efforts to apprehend the occupant of the Toyota Aristo and returning the helicopter to base was an available option but not one he considered realistic because the driver was wanted for serious offences and 45 Exhibit C164 46 Transcript, page 505 47 Transcript, page 511 48 Exhibit C148aar

there was a potential for him to commit further offences. It was a matter of public safety and police safety49. Furthermore, the driver knew that he was under observation.

14.7. The Commissioner very properly accepted that the incident should have been declared high risk and Inspector Teakle was also in agreement. However, as the Commissioner submitted, a declaration of the incident being high risk did not materially affect the outcome. Inspector Teakle gave evidence that he was managing the incident as if it were a high risk incident50 and that there was little he would have changed had he made the declaration. Inspector Teakle regarded the ideal outcome of the incident as a safe apprehension by means of a cordon and call or the suspect surrendering. Senior Sergeant Girardi and Sergeant Garlik both gave evidence that making a declaration of high risk would not have made a difference to the very fluid situation that confronted them that night51.

14.8. Finally, Chief Inspector Gray was critical of the failure of either Sergeant Leaker or Detective Hilliard to recall themselves to duty on receiving information about the sighting of the Toyota Aristo. Sergeant Leaker received information that it had been sighted at about 8:20pm that night. He did not recall himself to duty nor did he contact Detective Hilliard. Detective Hilliard was instead informed about the sighting by Detective Pratt. That occurred at 8:30pm. Detective Hilliard did not recall herself or other Operation Decipher members to duty. She maintained that she was only aware of one sighting of the Toyota Aristo. Furthermore, Inspector Dunstan was not advised that the Toyota had been sighted and was involved in a high speed pursuit in Eastern Adelaide’s area. Detective Hilliard did not take it upon herself to contact Inspector Dunstan.

14.9. Detective Hilliard in her evidence said that on her understanding of the information presented to her there had only been one sighting of the vehicle and it was then lost.

In the circumstances I am not prepared to be critical of Detective Hilliard for not recalling herself to duty in those circumstances.

14.10. In summary, it is my opinion that Brevet Sergeant Moir acted appropriately and in the proper lawful discharge of his duties when he shot Mr Quinn. It was suggested by 49 Transcript, page 512 50 Transcript, page 503 51 Transcript, pages 653 and 682

counsel for Mr Quinn’s family that there were some unusual features concerning the positioning of Mr Quinn’s body in relation to a cartridge case from Sergeant Moir’s Glock pistol which was eventually found underneath Mr Quinn’s body. Counsel for Mr Quinn’s family posed the question ‘how could a cartridge end up underneath a body?’. The logic inherent in such a question would be difficult to meet if it were not for the fact that a number of things happened after Mr Quinn was shot. Principally among those things were significant efforts made by more than one person, including Sergeant Moir and Sergeant Michael, to resuscitate Mr Quinn. Furthermore, Mr Quinn was also examined by a member of the ambulance service. It would be possible, in fact probable, that in the course of an emergency effort to resuscitate a person grievously wounded that his body may be moved in the process. Furthermore, it would also be possible that one of the party attempting to resuscitate Mr Quinn may have knocked the cartridge case into a position underneath Mr Quinn simply by bumping it with his foot in the course of moving around Mr Quinn in order to effect CPR. In my opinion the position of the cartridge case is easily explained on this basis.

15. Recommendations 15.1. I have no recommendations to make in this matter.

Key Words: Death in Custody; Police In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 2nd day of October, 2013.

State Coroner Inquest Number 28/2012 (1446/2010)