Coroner's Finding: ROBINSON Shane Andrew

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 24th day of November 2011, the 2nd, 6th 7th, 8th, 9th and 10th days of February 2012, the 22nd, 23rd, 24th and 25th days of May 2012, the 13th and 14th days of June 2012 and the 14th day of February 2013, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Shane Andrew Robinson.

The said Court finds that Shane Andrew Robinson aged 32 years, late of 5 Oldfield Street, Parafield Gardens, South Australia died at Bullyaninnie Station, Nackara CMB via Yunta, South Australia on the 9th day of July 2009 as a result of gunshot wound to head. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Shane Andrew Robinson died on 9 July 2009. He was aged 32 years. The cause of death at post-mortem was gunshot wound to the head1 and I so find. At the time of his death Mr Robinson was attempting to escape from the police and evade arrest. He was inside the homestead of a remote rural property owned by an elderly lady who was present in the house and who had been taken hostage and sexually assaulted by Mr Robinson. Using one of the firearms owned by the elderly lady, Mr Robinson took his own life. As he was evading police capture at the time of his death (police were in the area and had cordoned the house) Mr Robinson’s death was a death in custody and this Inquest was held as required by section 21(1)(a) of the Coroners Act 2003.

1 Exhibit C3a

2. Background 2.1. Mr Robinson was one of four children. His early years involved a number of changes of address amongst various country towns within South Australia and New South Wales. At the age of 2 his parents separated and Mr Robinson was cared for by his father who was an alcoholic and frequently violent. At the age of 12 Mr Robinson returned to the care of his mother however she was unable to cope with his behaviour and he was sent to live in a boys’ home. Mr Robinson began using cannabis at the age of 12 and at the age of 13 or 14 years he became a frequent user of amphetamines and then heroin. At the height of his addiction he was using $400 per day worth of heroin and sold drugs and engaged in other criminal activity to fund his habit. He came into contact with the criminal justice system at the age of 15 and spent a considerable amount of time in juvenile institutions and then adult gaols. His criminal history was extensive with wide ranging offending including serious dishonesty offences, break and enters, violence and sexual assault. The sexual assaults related to two girls, one aged 12 and one aged 16. As a result of that offending Mr Robinson was classified as a paedophile and was registered on the Australian National Child Offender Register (ANCOR) on 10 June 2008 under legislation which had recently been enacted for the purposes of registering sexual offenders against children.

2.2. In 2002 Mr Robinson was involved in a siege with police. On 30 April 2002 he was detected by police behaving suspiciously in the grounds of the Pines Nursing Complex at Netley. After being questioned by police he fled the scene and was located nearby. He again fled and entered a residence in Netley by forcing a laundry door. He took the only occupant of the premises hostage. This was a 17 year old boy.

Over the next 4 hours Mr Robinson held the boy hostage and threatened him with an axe. He held a knife to the boy’s throat on a number of occasions. He stabbed the bedroom walls and bedding with the knife and propped items against windows to block sight from outside. During the siege he walked from the bedroom using the boy as a shield, holding a knife to the boy’s throat. A STAR Group officer fired a single shot that passed through the shoulder of the hostage and struck Mr Robinson in the neck. Mr Robinson was arrested and remanded in custody. Due to his injuries he spent approximately 2 months at the Royal Adelaide Hospital undergoing treatment for the bullet wound.

2.3. As a result of that offending Mr Robinson was sentenced to just over 6 years imprisonment with a non-parole period of 4 years.

2.4. The following is a synopsis of Mr Robinson’s period on parole. I will elaborate further later on in this finding.

2.5. Mr Robinson was released on parole on 22 December 2007. Had Mr Robinson lived, the parole would have expired on 28 January 2011. In January 2008 Mr Robinson was charged with larceny and resisting police. On 20 February 2008 he allegedly committed a serious criminal trespass and theft. Also in January 2008 he failed to report for supervision resulting in the issue of a Parole Board warrant. On 26 February 2008 he was again involved in a siege with police however there was no innocent third party on this occasion and he was arrested safely. Mr Robinson was granted bail for those offences and ultimately released from detention on 15 May

2008. From that time he was under the supervision of Elizabeth Community Corrections. Shortly thereafter, on 3 June 2008, his parole officer minuted the Parole Board about his reluctance to participate in rehabilitative programs. On 26 June 2008 he returned a positive urinalysis for cannabis and the Parole Board was advised.

Subsequently a domestic violence allegation was made against him by his partner, Wendy Shorne. She advised that his whereabouts were unknown and he failed to report for supervision. The Parole Board was advised. On 31 October 2008 a Parole Board warrant was issued for his arrest. He was arrested the same day and was released from this period of detention on 25 November 2008 after Wendy Shorne gave assurances as to her willingness to have him residing at her address.

2.6. On 27 January 2009 Mr Robinson was convicted in the Adelaide Magistrates Court of some of the offending that occurred in January and February 2008. There was no sentence of imprisonment as time spent in custody was taken into account. On 16 March 2009 Mr Robinson was convicted of the offence of resist arrest that occurred in February 2008. Again, no period of imprisonment was imposed due to time already spent in custody. As a result of all of this his parole continued. In the ensuing months covering the first half of 2009 he continued to avoid participation in rehabilitative programs and his record for reporting for parole supervision was poor. He returned a positive urinalysis for cannabis again. On 2 June 2009 Elizabeth Community Corrections received a call from Mr Robinson’s partner, Wendy Shorne, claiming that Mr Robinson had broken into her home after she had locked him out and assaulted

her, including attempted strangulation. Ms Shorne said that he was no longer welcome at that address. On 5 June 2009 however, Mr Robinson called his parole officer and on 9 June 2009 he reported for supervision stating that he was residing with Ms Shorne. On 9 June 2009 Community Corrections officers visited the home of Ms Shorne to check upon her welfare. The following day, 10 June 2009, Ms Shorne contacted Elizabeth Community Corrections to advise that Mr Robinson was residing with her and that she was happy with that situation. On 19 June 2009 Mr Robinson failed to report for supervision. On 22 June 2009 Detective Sergeant Kelly Clarke from Elizabeth CIB informed the Elizabeth Community Corrections office that police wanted to interview Mr Robinson in connection with allegations of serious criminal trespass and theft. Furthermore, she advised that members of Elizabeth CIB had visited Ms Shorne’s address and been told that she and Mr Robinson were no longer in a relationship and he no longer resided at her address. This information was forwarded to the Parole Board and a warrant for his arrest was issued the following day, namely 23 June 2009. Thereafter a number of attempts were made by police to locate Mr Robinson without any success until he was detected on 9 July 2009 on the Barrier Highway.

2.7. The following is a summary of the events of 8 and 9 July 2009.

2.8. On Wednesday 8 July 2009 Brevet Sergeant Steinbeck was off duty at home when he received a phone call from the owner of the Caltex Roadhouse at Yunta. He was informed that there was a male walking on the highway. He went to the police station and communicated with truck drivers in the area on the UHF channel to seek advice of any sightings of this person. A number of truck drivers were in the area however none reported seeing him. At about 4am on 9 July 2009 Brevet Sergeant Steinbeck received a phone call from the Port Pirie police station regarding a collision. Details were limited however a location was given and he made his way to the scene, approximately 35 kilometres south west of Yunta. He requested that an ambulance and the CFS attend. He arrived at the scene at 4:20am and located a vehicle that had rolled over. He searched the area around the rollover but did not locate anyone. He conducted a motor vehicle registration check which showed that the plates on the vehicle were from New South Wales but they did not match the vehicle. The plates belonged to a resident of Broken Hill, a Dennis Adams, who was later found to be linked with Mr Robinson through his family. Brevet Sergeant Steinbeck checked the

registration label on the vehicle and noted that it was a South Australian registration number and further checks showed that the registration had expired. The vehicle was registered in the name of Mr Robinson’s grandmother. Also located in the vehicle was a small amount of cannabis and cans of alcohol, a flat screen television and a DVD player. This property was ultimately linked to a house in Burra North where a serious criminal trespass had been reported to have occurred on 4 July 2009.

2.9. Brevet Sergeant Jeffrey Allen was the officer in charge of the Mannahill police station. At 6am on 9 July 2009 he was tasked to attend a location on the Barrier Highway approximately 15 kilometres south west of Yunta in response to a report from a truck driver that a male was seen walking along the highway at that point. On arriving in the vicinity, Brevet Sergeant Allen saw a man walking east on the northern side of the road’s shoulder. He was cradling a white dog in his jacket and Brevet Sergeant Allen slowed down. The man kept walking. Brevet Sergeant Allen stopped his vehicle and walked towards the man. He activated his police vehicle camera and also had a microphone in his pocket. Brevet Sergeant Allen asked the man if he had been involved in a car accident at Oodla Wirra and the man confirmed that he had been. He was given a caution and explained that SAPOL were investigating the accident and was asked for his correct name. The man stated that he was Shane Andrew Robinson. He provided a date of birth and address and these details were written in Brevet Sergeant Allen’s notebook. Brevet Sergeant Allen asked him if he had anything in his possession that he should not have and he replied that he had some ‘dope’. He said that it was in his right sock and Brevet Sergeant Allen asked him to take it out. Mr Robinson crouched down and moved towards his right foot. As he bent down the dog fell onto the ground and Mr Robinson then made contact with Brevet Sergeant Allen’s left arm and hit his right shoulder. Brevet Sergeant Allen felt something stabbing his right shoulder and saw Mr Robinson pull back. He knew that he had been stabbed. He attempted to draw his firearm but he had no strength in his right hand and could not unclip the holder clasp. Shortly afterwards, Brevet Sergeant Allen collapsed.

2.10. At that point Mr Robinson stole the police vehicle and drove off in it at speed. Brevet Sergeant Allen waved down an approaching vehicle, identified himself as a police officer and obtained assistance. He alerted his base via police radio and advised them that he had been stabbed. A search then ensued and at approximately 10:40am the

police vehicle was located parked in front of the homestead to which I have already referred. This was the homestead that was occupied by the elderly lady to whom I have already made reference. A siege then ensued and at 11:38am the elderly lady emerged from the house to advise that the male inside the house had shot himself and she believed he was dead.

3. Mr Kevin Hill 3.1. Mr Hill is the Secretary and Executive Officer of the Parole Board. He gave evidence at the Inquest. He explained that the Parole Board relied on Community Corrections officers to monitor a parolee’s compliance with conditions of parole and to report back to the Parole Board with any concerns. In his evidence Mr Hill went through the file of Mr Robinson in considerable detail. He explained the three occasions on which Mr Robinson was brought before the Parole Board to answer allegations of breaches of his parole. These three occasions occurred between January 2008 and May 2009. The Parole Board’s file showed a prompt response by the Board to the minutes of concern that were sent by Mr Robinson’s Community Corrections’ officers. Mr Hill told the Court that Mr Robinson was before the Parole Board for a number of matters including failing to report for supervision, monitoring for further offending before the Court and perhaps, most importantly, positive urinalysis. On two occasions a Parole Board warrant was issued for Mr Robinson’s arrest and on one occasion he was held in custody awaiting the Parole Board hearing. This does not include the Parole Board warrant that was issued on 24 June 2009.

4. Ms Assunta Russo 4.1. Ms Russo was Mr Robinson’s first Community Corrections officer. She was based at the Port Adelaide Community Corrections Centre. The evidence showed that Ms Russo’s supervision of Mr Robinson was adequate and competent.

5. Elizabeth Community Corrections 5.1. Mr Robinson was managed by Elizabeth Community Corrections from May 2008 until his death. Elizabeth Community Corrections was aware that he was residing at Parafield Gardens with his partner, Ms Shorne. He was assigned Ms Iagrossi as his case manager. Ms Iagrossi gave evidence. She said that the conduct of urinalysis testing was not an easy task. This was a matter of concern given the high proportion

of parolees who were on parole for drug related offending. Obviously they needed to be monitored for illicit drug use. Mr Robinson was such an offender. Ms Iagrossi gave evidence that at the time she was supervising Mr Robinson there was one alcohol and other drug testing unit which would visit the Elizabeth office on a fortnightly basis. The service was not available at all between Christmas and New Year. In my view this is clearly undesirable as that is a period when one would expect that parolees would be tempted to consume alcohol and other drugs. A thorough testing regime would target such a period. One might ask oneself why, if the police force makes a practice of upgrading its efforts in relation to random drug and breath testing during peak periods such as between Christmas and New Year, a like focus is not applied by Correctional Services to the behaviour of parolees during such periods.

5.2. The evidence showed that a difficulty in Mr Robinson’s supervision arose when Ms Iagrossi went on leave. When this occurred her caseload of high risk parolees, including Mr Robinson, was monitored by Ms Fiona Beevor who was Ms Iagrossi’s supervisor. The practice of Community Corrections at that time was that during a period of leave, the parolees assigned to the person who was absent would be monitored to the extent only of checking that each parolee was reporting for supervision. Furthermore, the parolee did not need to report to the monitoring person directly for supervision, but to the duty officer. The duty officer was a person assigned on a particular day to the general task of taking reports from parolees when their own parole officer was not present. Thus the opportunity for things to be missed was considerable. In particular, there was no guarantee of continuity of supervision.

In my view this is a matter of concern.

6. The domestic violence allegation 6.1. On 2 June 2009 Ms Shorne (Mr Robinson’s partner) contacted the Elizabeth Community Corrections office to notify them that Mr Robinson had attempted to strangle her and had broken into her house after she had locked him out. She said that he was no longer living at that nominated residence. At that time Ms Beevor was acting in Ms Iagrossi’s place but only to the extent of monitoring Mr Robinson. She rang the SAPOL Call Centre to advise police about Ms Shorne’s contact. According to a note on the file she also notified ANCOR. Ms Beevor did not notify the Parole Board of the allegation of domestic violence and accepted in her evidence that she

should have done so. When, on 5 June 2009 Mr Robinson did not report for supervision, Ms Beevor again did not report this matter to the Parole Board. Once again, she accepted in her evidence that she should have done so. On 9 June 2009 Ms Beevor attempted to contact Ms Shorne to check on her welfare. On that day a home visit was conducted by Mr Shillabeer to check on Ms Shorne’s safety and also to see if Mr Robinson was residing at her address. The home visit did not shed light on either matter conclusively and yet the Parole Board was still not notified. Both Ms Beevor and Mr Shillabeer agreed in their evidence that the Parole Board should have been notified at this point. When one considers the way in which the Parole Board reacted to previous notifications of breaches, it is likely in my opinion that the Parole Board would have taken action promptly had it been notified of any of these events.

7. Ms Beevor’s call to SAPOL on 2 June 2009 7.1. As I have said, Ms Beevor contacted the SAPOL Call Centre to advise of the allegation by Ms Shorne. The Court obtained the recordings of this telephone conversation and a transcript was made2.

7.2. The content of this communication is most important and I set it out in full: 'Call to SAPOL Call Centre by Fiona Beevor SAPOL: South Australian Police FB: Yes hi I um can I report something SAPOL: Well that depends on what it is FB: Yes um I work for Elizabeth Community Correctional Centre and one of our parolees partners rang and said that um she had um asked the partner to leave the premises last night and not to live there and he has broken in and assaulted her last night and she is too fearful to contact the police so she rang us knowing that we would have to.

SAPOL: Right so she is home at the moment.

FB: Yes well she rang our duty officer SAPOL: So is she home FB: Her um we didn’t get those details SAPOL: Well we need to know where she is to be able to take a report from her or she needs to FB: I know her name and address 2 Exhibits C146 and C146a respectively

SAPOL: Yep but FB: Because that is where he lives SAPOL: But unless she is there – um I will just talk to my Sergeant SAPOL: Follow up, I have just had a chat with my Sergeant do you actually have a phone number for her where she can be contacted FB: Yes SAPOL: Right, if she doesn’t wish to take it any further though we can’t make her FB: No that’s fine, we are fully aware of that we just thought that because she’s stated that she’s um been assaulted last night and he broke into her property to assault her that obviously it is still a police matter SAPOL: Yes but we can’t, but yeah, but we can’t make her say that that has happened FB: No.

SAPOL: What is her phone number there FB: Her name is Wendy Shorne and her phone number is 0000 0000 SAPOL: Ok then FB: Thank you, bye'

7.3. Following this communication from Ms Beevor, the SAPOL Call Centre operator made contact with Ms Shorne. That phone call was also recorded and transcribed. I set it out in full: 'Call between SAPOL and Wendy Shorne WS: Hello SAPOL: Hi may I speak with Wendy please WS: Speaking SAPOL: Hi its Bronwyn from South Australian Police, we have just had a call from Correctional Services saying that you were assaulted last night. Are you wanting to report this to the police?

WS: No.

SAPOL: Ok, that’s alright I just needed to check.

WS: No, thank you SAPOL: Bye' 3

7.4. The contact between the SAPOL Call Centre operator, Bronwyn, and Ms Shorne was extremely concerning. It is almost shocking in its brevity. I listened closely to the 3 Exhibit C136

recording itself. The transcription conveys the sense that the call was perfunctory.

This impression is strongly reinforced on listening to the recording itself.

7.5. In the course of the Inquest I examined the police General Orders in place at the time and the standard operating procedures applicable to Call Centre operators and how they should deal with reports of domestic violence. These documents applied not only to members of the police force, but also to administrative support officers. It should be noted that the Call Centre operator who made the phone call referred to above to Ms Shorne was not a member of the police force, but was an administrative officer.

7.6. Neither the police General Orders nor the standard operating procedures made specific provision for the situation in which domestic violence is reported by an employee of another Government agency to SAPOL. Nevertheless, the underlying principals of both documents are very clear, namely that the safety of the victim and any children who may be at risk are paramount.

7.7. The call taker in this instance was Ms Bronwyn Trinne. She gave evidence. Ms Trinne was an ASO2 administrative officer. She said that during the call from Ms Beevor she sought assistance from her supervising Sergeant. This is corroborated by the transcript itself in which she states that she is going to do just that, and by the recording in which there is a pause while the consultation occurred.

7.8. The evidence showed that the supervising Sergeant was one of three people, namely Senior Constable Kaye, Sergeant Gardiner or Sergeant Drewry. All of these police officers were on duty at the Call Centre for that day to assist call takers and carry out supervision. Both Senior Constable Kaye and Sergeant Drewry gave evidence that they would not have given the advice to Ms Trinne to contact the victim to ask if she wanted to report the assault. Sergeant Gardiner on the other hand was reluctant to admit that there was anything fundamentally wrong with this approach and his oral evidence was largely supported by the statement that he gave to the Court. It was his view that if a victim of domestic violence is not willing to present herself to a police station to make a report then there is little more that the police can do. It goes without saying that this is a completely inappropriate position for a senior police officer responsible for the supervision of administration officers taking calls from victims of domestic violence to adopt. It was not the position adopted by either of his fellow

supervisors. The likelihood is that it was Sergeant Gardiner who took the enquiry from Ms Trinne on 2 June 2009, although the evidence does not allow me to reach any firm conclusion about that.

7.9. Each of the three supervising officers gave evidence in this case. None of them had a recollection one way or the other as to whether they were the person to whom Ms Trinne spoke on the day. Each of the three though gave evidence that the operating procedures and the General Order stated that: '1 The safety and immediate welfare of the victim and children must be taken into account;

2. That the whereabouts of the offender must be considered;

3. That the risk of further victimisation must be considered;'

4. The use or presence of weapons must be considered;

5. The parole status and previous offending history of the alleged offender must be taken in account;

6. That police should adopt a positive and proactive approach.' 4 Indeed, the two documents certainly reflect this as the correct approach.

7.10. Senior Constable Kaye and Sergeant Drewry each gave evidence that they would have directed further enquiries to be made of Ms Beevor to establish a basis on which to take the above matters into account. Sergeant Drewry gave evidence that he believed it appropriate to task an ASO Call Centre operator to initially investigate those matters with the victim. Senior Constable Kaye gave evidence that a SAPOL supervisor or a SAPOL patrol would have been the appropriate means to conduct further investigations. Sergeant Gardiner on the other hand gave evidence that it is reasonable to require Ms Shorne to attend a police station to make a report, rather than ‘tie up a patrol when the person could have gone to a police station’5. This could only have been based on the unfounded assumption that there was no immediate danger because the alleged offending took place the previous night and therefore the offender was not present or posing an immediate danger. One of the great difficulties in all of this is that the approach taken by Ms Trinne at the direction of her supervisor completely failed to address the serious possibility that Mr Robinson was present in the house at the time when the perfunctory phone call was made by Ms Trinne to Ms 4 Exhibit C138a 5 Transcript, page 622

Shorne. Indeed, in reading the transcript or listening to the recording of the telephone conversation, the monosyllabic responses of Ms Shorne are entirely consistent with a person trying to conceal from another person present in the house the nature of the telephone call. In other words, it would be entirely reasonable to read her response as the very response one would expect from a person when the offender is present and listening.

7.11. Sergeant Gardiner’s response in particular is contrary to the General Orders and the standard operating procedures.

7.12. On any view there is a difference of approach between all three supervisors. While Sergeant Gardiner was significantly more blasé in his approach than either of his colleagues, there were differences between Senior Constable Kaye’s and Sergeant Drewry’s approach as well. Even more significantly, there was a slightly different approach from the officer in charge of the Call Centre itself, Chief Inspector Bahr. In my opinion there is no doubt that Senior Constable Kaye’s approach was that which was most appropriate, or would have been most appropriate had she been the person who had given Ms Trinne the guidance. Her approach was in line with supporting General Orders and standard operating procedures. Senior Constable Kaye had a special interest in the area of domestic violence and has undergone training in that area. It is perhaps not surprising then that hers was the best response. In my view this supports the need for adequate training in staff who are at the frontline in taking reports of domestic violence.

7.13. I conclude that the call to Ms Shorne was handled entirely inappropriately and should never have taken place. I do not believe that Ms Trinne should have been calling Ms Shorne at all having regard to the information which had been forthcoming from Ms Beevor and that which had not yet been ascertained. Ms Beevor had enough information in her possession for a patrol car to be despatched to the house to check on Ms Shorne’s welfare. Had that been handled with sensitivity by the patrol (assuming one had been despatched) Ms Shorne may have been more forthcoming.

However, the outcome of such a visit will never be known. Predictably, when she was called by telephone in the perfunctory manner adopted by Ms Trinne, she said she did not want to report the matter and nothing further was done.

8. Failure to Investigate the Perpetrator’s Identity 8.1 It is clear from the evidence that the extent of attention given to the report of Ms Beevor was as set out in the transcript of the two calls. It can be seen that there was no attempt to ascertain the identity of the perpetrator of the domestic violence. Yet the caller was from Community Corrections, and it was clearly stated that the perpetrator was a parolee, and furthermore that had had been asked to leave his place of residence.

8.2 If a member of SAPOL had established that the parolee was Mr Robinson, and had conducted some basic checks on PIMS, it would have been obvious that Mr Robinson was not just anyone. For example, such a check was capable of revealing the information entered into PIMS by Brevet Sergeant Woods which set out below in more detail. For present purposes it is sufficient to note that information included the fact that Mr Robinson had “a long and violent criminal history” culminating in him being shot by STAR after a siege involving a hostage held at knifepoint. It would have alerted the inquirer to Mr Robinson’s “simmering” “deep seated hatred of police”, and that concerns had been expressed that he might have access to drugs thus increasing the risk of violent behaviour. The searcher would have learnt that the following warnings existed for Mr Robinson:  May be armed  Drug user /dependant  Conviction prescribed kind  CSO finalised diary  May assault police  Disease – confirmed communicable  May try to escape 8.3 Despite Ms Beevor’s contact with the call centre, none of this occurred. As will be seen later, the Deputy Comissioner of Police had expressed a particular interest in Mr Robinson. Despite all this, no inquiry was made of PIMS about Mr Robinson. No inquiry was even made to establish who Mr Robinson was. None of the SAPOL people, namely Ms Trinne, or any of Senior Constable Kaye, Sergeant Drewry and Sergeant Gardiner, thought to establish the identity of this parolee who was the

subject of reported domestic violence and not living at his probable nominated residence.

8.4 Ms Trinne was aware that he was a parolee. Her evidence was that she would probably have conveyed to her supervisor that the call was being made by correctional services6. Thus, the supervisor was in a position to infer that the perpetrator was a parolee even if Ms TRinne had not mentioned that specific detail.

Had the supervisor asked “was it a parolee?” Ms Trinne would certainly have answered in the affirmative – having just been told that by Ms Beevor.

8.5 In giving evidence, Ms Trinne placed no particular significance on the fact that the perpetrator was a parolee, saying that “at the call centre, we don’t do breaches of parole”7, and “the parolee thing doesn’t really mean much to me really8”. This evidence shows quite clearly the reason why I have concluded that administrative staff at the call centre should not be involved in making decisions about important matters, and certainly should not be making calls to victims of domestic violence to see if they wish to make a complaint to police.

8.6 Unsurprisingly, the most sensible evidence on this topic came from Senior Constable Kaye, who volunteered without any prompting that the fact that the perpetrator was a parolee was significant and that he had probably placed himself in breach of his parole by the act of domestic violence and that she would have interrogated PIMS for further information about him. This reinforces the view that she was not the supervisor to whom Trinne reported. Had she been, things may have ended differently and the tragic events of 9 and 10 July 2009 may have been averted.

8.7 Remarkably, Sergeant Drewry attached no significance to the information that the perpetrator was a parolee9 and that PIMS might have yielded further intelligence about him10. Predictably Sergeant Gardiner’s was the most indifferent attitude. He said the status of parolee would not make any difference to his response. The following gives some idea of the flavour of his evidence:

6 T533 7 T538 8 T540 9 T613 10 T614

Q If you’d had that information, all that extra information and that information about the parolee had come back with a long history, would you have tasked a patrol then.

A Still – no not really, because it – again there was no indication that the offender was still there and if it would be a matter that the incident would be followed up by police at a later date.

CORONER Q It wouldn’t be would it. It wouldn’t be followed up by police at a later date would it.

A If the victim had gone to a police station and reported it, or wanted it reported.

Q Only if the victim went to a police station.

A Yes.

Q Otherwise nothing would happen.

A No.

Q In fact all that would happen would be that Mr Robinson who was a parolee, would commit a violent act against among others, a police officer one month later, correct?

A Yes, correct. But at the same time I would assume that the corrections officer who’d been already advised, would have been taking some sort of action as well.

Q Yes, she rang the police. Go on.” 8.8 When Sergeant Gardiner gave that evidence he was aware of Mr Robinson’s subsequent rampage around the mid-north of the State, involving as it did the wounding of a fellow officer and the sexual assault and holding hostage of an elderly lady. Yet even with that knowledge his answers showed no sense of urgency, no acknowledgement that as a police officer it was possible to take advantage of PIMS and obtain further information about this parolee that might have been followed up with the result that what followed might have been prevented. Sergeant Gardiner displayed what can only be described as a complacent attitude. Clearly if the same situation occurred in the future and he were involved, he would act in the same way as he (or whoever the supervisor actually was) acted in 2009. I mention this in the hope that his managers may be able to offer him training or guidance that will encourage him to adopt the constructive and inquiring approach shown by Senior Constable Kaye.

9. Australian National Child Offender Register (ANCOR) 9.1 The South Australian Parliament enacted the Child Sex Offenders Registration Act

10. It came into operation on 18 October 2007. It was enacted pursuant to an inter-

governmental agreement between the Commonwealth of Australia and all of the States and Territories of Australia, including of course South Australia. The agreement was made on 1 July 2000 and provided for the establishment of ‘CrimTrac’ which is a national law enforcement information system for Australia’s police services. The inter-governmental agreement contemplates the establishment of a national child sex offender system. CrimTrac has a website11 which refers to child protection services. It states as follows: 'CrimTrac is responsible for the ongoing delivery of the child offender register services and the development of technologies that support the management of child offenders and the investigation of child exploitation.' It further states: 'The general objective of the legislation is to ensure that persons convicted of sex offences and other serious offences against children are able to be monitored by police once they have served their sentence. ' The website makes reference to the legislation of all of the States and Territories and I note that each State and Territory has made legislation corresponding with the Child Sex Offenders Registration Act 2006 of South Australia. As at March 2011 the website states that there were 12,596 registered offenders across Australia.

9.2 The Child Sex Offenders Registration Act 2006 of South Australia sets out its objects in section 3. They are as follows: 'The object of this Act is to protect children from sexual predators by—

(a) requiring certain persons who may have a propensity to commit sexual offences against children to keep the Commissioner of Police informed of their whereabouts and other personal details for a period of time—

(i) to reduce the risk of such offences being committed; and (ii) to facilitate the investigation and prosecution of any offences that are committed; and

(b) preventing such persons from engaging in child-related work.' The Act requires that persons to whom it applies, namely persons who have committed sexual offences against children, must be registered under a register maintained by South Australia Police. It requires that a person so registered must report his or her personal details to the Commissioner of Police each year. The Act is 11 To be found at www.crimtrac.gov.au

a significant piece of legislation covering 73 sections and some 40 odd pages. The Act provides for an impressive legislative scheme of monitoring of child sex offenders and for considerable powers for that scheme to be implemented.

9.3 I have earlier referred to the fact that Mr Robinson’s criminal history of convictions includes two offences against children. His SAPOL records refer to a number of other reports of offences against children, but these did not result in convictions. The two offences that did result in convictions related to a 12 year old girl and a 16 year old girl respectively. Each of the offences was serious involving penile rape. It followed therefore that Mr Robinson was a person required to be registered under the Child Sex Offenders Registration Act 2006 of South Australia after it came into operation in October 2007. In fact, Mr Robinson was registered on 10 June 2008.

The ANCOR file was tendered12 and contains a telling account of Mr Robinson’s presentation for registration on that day in an email from Detective Brevet Sergeant Steven Woods employed in what is described as the Elizabeth ANCOR Unit. The email is sent to a number of other officers, all of whom were involved in some way in SAPOL’s ANCOR activities. The email is significant and I set it out hereunder: 'This is a short email in relation to an ANCOR subject that I registered yesterday, Shane Andrew Robinson, 31 years of Parafield Gardens. Robinson has a long and violent criminal history, which culminated in him being shot in the face by STAR Division officers after a siege in which he held the occupant of a house he had broken into at knifepoint.

I have a number of concerns in relation to Robinson. Although I registered him without any real drama, I could tell that he was simmering throughout. All I had to do was push the right button and World War III would have erupted. He has a deep seated hatred of police and I would urge any police officer dealing with him to use extreme caution13. I am unsure if any mention of Robinson’s new address has been made via the daily whisper or similar, just to forewarn local police? (I have been on leave so am unaware if this has been done in the last three weeks). As he is now living in our patch this information should be widely disseminated. He is living with a suspected drug dealer, Wendy Shorne, who he claims is his partner. Recent ancillaries on the PIMS14 suggest she is actively dealing. Having Robinson on the scene can only exacerbate the potential for increased dealing and/or violence, I believe.

Wendy Shorne has four daughters living with her, aged 14, 16, 18 and 19 years of age (this information was provided by Robinson himself). In view of Robinson’s past history (he has been charged numerous times with sex offences most of which appear to have been dismissed, acquitted or withdrawn) then I query if this is an ideal situation. I 12 Exhibit C151 13 Angelo Calandro, who will be referred to later in this finding, was one of the officers to whom the email was directed 14 Police Information Management System

am unaware if Wendy Shorne is aware of Robinson’s complete history. I am also of the opinion that if I submit a CARL15 notification as I have done in the past with other offenders, then I may well be igniting the fuse which sets him right off. In addition I would hate to see a representative from FYS16 come to grief when they action any such notification.

In short I think this bloke is trouble. I am promulgating this email to make all aware of Robinson and his presence in our LSA. Your collective thoughts and suggestions on the issues I have raised would be much appreciated.' 9.4 This email is self explanatory and requires no particular comment other than to say that the observations made were very pertinent and relevant and should have served to put all who had any further dealings with Mr Robinson on their guard and on a high state of alert.

9.5 The file also contains another email, this one dated 15 February 2008. This email is to a number of recipients including one who was also a recipient of the email from Detective Brevet Sergeant Woods. This email notes that as at 15 February 2008 Mr Robinson was currently wanted for a parole warrant. It also refers to him being wanted for an ANCOR breach, although this may not be correct given that Mr Robinson was not then registered under the ANCOR legislation (however this is not important for the purposes of this finding). The email contains some information about Mr Robinson and his possible whereabouts. Significantly it contains the following sentence: 'I believe that Gary Burns has a personal interest in Robinson and wanted to be kept in the loop.' The Gary Burns referred to in the email was then Deputy Commissioner of Police and at the date of the Inquest and this finding is the Commissioner of Police.

9.6 This also requires no elaboration from me other than to note that, again, it indicates that Mr Robinson was sufficiently notorious and dangerous to have attracted the attention of an officer who was then the second most senior member of SAPOL. It should have again served to have underlined to all users of this file that Mr Robinson was an offender who required very careful handling and the highest level of diligence both to protect police and others who came into contact with him, and the community in general.

15 Child Abuse Report Line 16 Family and Youth Services

9.7 The information contained in the email from Detective Brevet Sergeant Woods was disseminated to the wider police community by means of an ancillary report in the PIMS. This was then available to all members of the police force including patrols, call centre staff, ANCOR staff – any member of the police force who had access to PIMS. Ms Fiona Beevor from the Department for Correctional Services contacted an officer from ANCOR on 9 June 2009 to express concern that Mr Robinson was suspected not to be residing at the nominated address, namely the address of Ms Shorne. Furthermore, she advised that she was concerned about Ms Shorne’s welfare.

This call most likely was received by an officer by the name of Angelo Calandro, a member of the Police Intelligence Section at Elizabeth. Senior Sergeant Calandro then promptly disseminated this information to the relevant people, incorporating also a reference to events that had taken place on 4 June 2009 when Mr Robinson was reported by Ms Shorne and her son to have been driving past the house acting in ‘a threatening and assaulting manner’. Those words were used in an ancillary report within PIMS. He disseminated this information via an email sent at 1:09pm on 9 June

200917. It was forwarded on by Detective Senior Constable First Class Chamberlain to Detective Brevet Sergeant Rae and Detective Brevet Sergeant Tester of the Adelaide branch of the SAPOL’s ANCOR. Detective Senior Constable First Class Chamberlain was enquiring whether Detective Brevet Sergeant Rae and Detective Brevet Sergeant Tester would be investigating the matter. This was because Mr Robinson was designated as a high risk offender for the purposes of the ANCOR regime and high risk offenders were supposed to be managed from the Adelaide ANCOR office. Detective Brevet Sergeant Tester and Detective Brevet Sergeant Rae were both stationed at the Adelaide ANCOR office18. The email was clearly addressed to Detective Brevet Sergeant Rae as the nominated case manager.

However, Detective Brevet Sergeant Tester was also a recipient of the email.

9.8 Both Detective Brevet Sergeant Rae and Detective Brevet Sergeant Tester gave evidence at the Inquest. Detective Brevet Sergeant Rae told the Court that he and Detective Brevet Sergeant Tester shared a caseload and that although he could not specifically remember it, it was likely that he was at his desk when the email arrived.

He speculated that he would have spoken to Detective Brevet Sergeant Tester who was at an adjacent desk, as to whether Detective Brevet Sergeant Tester was going to 17 Exhibit C145 18 The evidence showed that the case management of registered offenders appeared to be a fluid arrangement. It lacked continuity and structure.

assume responsibility for the matter and Detective Brevet Sergeant Rae thought it likely that Detective Brevet Sergeant Tester had agreed that he would do so.

Detective Brevet Sergeant Tester on the other hand told me that he remembered the email but he had no memory of being asked to investigate it and assumed that Detective Brevet Sergeant Rae had done something about it. In the result no further action was taken by the ANCOR unit until 22 June 2009. The significant point to be noted is that ANCOR now had in its possession as at 9 June 2009 information that Mr Robinson was suspected not to be residing at his nominated address. There were also allegations that he was behaving in a threatening manner towards Ms Shorne and her teenage son. In the context of the earlier file note by Detective Brevet Sergeant Woods and the file note that referred to Deputy Commissioner Gary Burns’ interest in Mr Robinson, it is extremely concerning that, when this further alarming information about Mr Robinson’s behaviour was reported, nothing was done about the matter.

Had the matter been actioned at that point and proactively investigated, it is possible that Mr Robinson may have been detained at this point, or that at least police efforts to locate and detain him may have been escalated. If this had occurred then it is conceivable that the train of events which subsequently ensued might have been prevented with the result that the serious wounding of a police officer and the sexual assault of an elderly lady may have been prevented.

9.9 In my view, it was unsatisfactory that a high risk ANCOR offender such as Mr Robinson was not assigned a dedicated ANCOR case manager. While the evidence is that Mr Robinson was being case managed by Detective Brevet Sergeant Rae; that was not Detective Brevet Sergeant Rae’s evidence. His evidence was that he shared a caseload with Detective Brevet Sergeant Tester. The impression I gained from the evidence of the ANCOR witnesses was that the efforts of that unit were rather amateurish and far from ideal. I intend to recommend to the Commissioner of Police that proper resources be allocated to ensure that high risk offenders have dedicated case managers and, as far as is practicable, that the same case manager monitor high risk offenders throughout their time under ANCOR.

10. June 2009 – Further activities of Community Corrections 10.1 On 19 June 2009 Mr Robinson did not report for supervision. Ms Beevor gave evidence that despite Mr Robinson’s history and the events leading up to this failure to report, she would not have reported this non-attendance until she had given him an

opportunity to explain himself. That day was a Friday and Ms Beevor had an appointment to go home. On 29 June 2009 Mr Robinson had still not attended for supervision and was suspected of having committed further offences. This latter information was conveyed to Elizabeth Community Corrections by Detective Sergeant Kelly Clarke. Her notification was the catalyst for the Parole Board being notified and a warrant being issued for Mr Robinson’s arrest. Mr Hill, Secretary to the Parole Board, gave evidence that the Chair of the Parole Board expressed real concern to him that the earlier events had not been reported as soon as they occurred.

Once the Parole Board warrant was issued efforts to find Mr Robinson were unfortunately not successful despite the commendable diligence shown by Detective Sergeant Kelly Clarke.

11. Urinalysis 11.1 The evidence showed that the Parole Board requested a urinalysis test on 15 May 2009 and that it was not undertaken. It would appear that this was because Mr Robinson was not being actively managed by anyone at that point because Ms Iagrossi was on leave. This is an unsatisfactory situation and has resulted in significant changes within Community Corrections since and because of Mr Robinson’s death.

11.2 The evidence showed that urinalysis testing was limited by the resources available to the Department for Correctional Services for that purpose. I invited Senior Constable Peter Thompson to give evidence in relation to the system used by SAPOL to conduct random drug testing at the roadside for motorists. Senior Constable Thompson is an expert in this area and had presented to a number of conferences both nationally and internationally. He described the way in which random saliva testing is conducted at the roadside in a most helpful manner and his evidence was particularly useful. The effect of his evidence was that operators in random saliva testing need to be provided with quite intensive training. Nevertheless, it certainly seems to be a practical option which would offer support for urinalysis testing. It would enable monitoring to take place far more frequently than is presently the case. It could be done randomly more easily than the present urinalysis system. It is quicker and less resource intensive. In my view it would be extremely beneficial for the Department for Correctional Services to implement a system of random saliva testing to augment and supplement the urinalysis testing which is presently being done. I intend to recommend that the

Minister for Correctional Services implement a random saliva testing system based on the system employed by SAPOL for roadside testing of motorists as a supplement to the urinalysis testing presently used in the supervision of high risk parolees. It is known that many offenders, Mr Robinson included, have a propensity to commit serious offences while they are under the influence of illicit substances. Clearly it is in the interests of public safety that such offenders should be closely scrutinised in relation to their drug use. The evidence was that the urinalysis system is not available at all during, for example, the period between Christmas and New Year. That is clearly a time when the general public, including parolees, are more likely to be tempted to consume alcohol and other substances than normally. It seems to me that random saliva testing could be deployed at this time, even if urinalysis cannot be, because a much wider range of staff could be trained in saliva sampling. After all, if SAPOL is able to intensify its activities in relation to roadside monitoring of motorists during such festive periods as the Christmas/New Year period and other public holidays, it seems to me that there is every reason why the Department for Correctional Services should adopt the same stringent attitude in relation to parolees, who are a group known to be more likely to engage in bad behaviour and illicit drug use than the general motoring public.

12. Summary 12.1 There were opportunities to intervene in the management of Mr Robinson in a way that might have prevented the events culminating in his death, thus saving not only his life but the serious sexual assault of an elderly lady and the serious stabbing wounding of a member of the police force. These included the opportunities for ANCOR officers to have exercised greater diligence in scrutinising Mr Robinson. When one considers the elaborate nature of the framework under which ANCOR operates, namely an inter-governmental agreement, and legislation in all States and Territories, it is disappointing that on the ground the implementation of the scheme was not adequate to ensure more proactive policing in relation to Mr Robinson when it appeared that he was starting to behave erratically. Particularly is this so when one considers the information on the ANCOR file about Mr Robinson and the early predictions of Detective Brevet Sergeant Woods about his propensity to behave violently. The awareness of the potential of Mr Robinson to cause serious harm was

further underlined by the interest shown in his case by the then Deputy Commissioner of Police.

12.2 Detective Brevet Sergeant Woods’ email referred to the fact that Wendy Shorne had four teenage daughters living with her. His email poses the question: is it ‘an ideal situation’ for (I assume) Mr Robinson to be living with those children. He also notes that Ms Shorne may not be aware of Mr Robinson’s history of child sex offences.

When one considers that the entire point of the ANCOR system, the Child Sex Offenders Registration Act 2006 and the CRIMTRAC inter-governmental agreements is to protect children and monitor paedophiles, these comments, while clearly heading in the right direction, barely scratch the surface of the issue. The issue is, that paedophiles should not be living with children at all. Secondly, Ms Shorne should be made aware of Mr Robinson’s history, if there is any question that she was not already aware. Surely this is the fundamental point of the ANCOR system.

12.3 Furthermore, Detective Brevet Sergeant Woods’ email refers to the ‘option’ of making a ‘CARL’ notification – this is a reference to the Child Abuse Report Line, which is the agency that mandated notifiers are legally obliged to make reports about children suspected of being at risk so that child protection workers can investigate.

Police officers are mandated notifiers. Detective Brevet Sergeant Woods goes on in the email to say: ‘I would hate to see a representative of Family and Youth Services come to grief when they action any such notification’.

This is a prediction about Mr Robinson’s likely behaviour towards a hypothetical child protection worker. It goes without saying that this is a total misunderstanding of what ought to happen. The first priority should be to safeguard the children. The obligation upon a mandated notifier is just that – an obligation (the clue is to be found in the use of the word ‘mandated’). It is a bizarre form of reverse logic to contemplate a CARL notification and then dismiss it because the potential abuser is so dangerous that he might harm the people who are supposed to protect the children who are suspected to be at risk of harm at his hands.

12.4 Brevet Sergeant Woods’ email was sent to a number of SAPOL recipients. It appears that none of those officers identified that Brevet Sergeant Woods should have made a CARL notification, that he should have been concerned about the children rather than

some hypothetical child protection worker, and that in any event if there was doubt about the appropriateness of Mr Robinson’s living arrangements, they should have been addressed immediately, in keeping with the purposes for which ANCOR was established.

12.5 Fiona Beevor’s call to the SAPOL call centre was an inadequate response to the information she had received from Wendy Shorne. She was aware that Mr Robinson had attempted to strangle Ms Shorne. Strangulation is a known risk factor for high lethality in domestic violence. This should have been conveyed by Ms Beevor to the call centre operator. This suggests a need for further training for staff of Community Corrections which I address below.

12.6 The approach taken by the Call Centre when Ms Beevor reported the allegations of domestic violence against Mr Robinson was an occasion on which events had the potential to take a different course. In my opinion it was not appropriate for an administrative officer to make a call to a domestic violence victim in the circumstances in which Ms Trinne made such a call. I am not particularly critical of Ms Trinne in this regard, after all she was acting under direction. Nevertheless, her unsympathetic and perfunctory tone comes across very clearly in the audio recording, and even in the transcript of her telephone conversation with Ms Shorne. Little wonder that Ms Shorne did not take the opportunity to pursue the matter. While it might be suggested that Ms Shorne was not a person who would have encouraged police interest given her own criminal history, none of that was known to the Call Centre staff, including the supervising staff when the decision was made for Ms Trinne to make the contact with Ms Shorne. Presumably the same actions would have been taken in relation to any victim of domestic violence who happened to come to the attention of those people at that time. This is completely unsatisfactory. In my opinion, domestic violence reports should not be dealt with by Call Centre operators in this manner. In my opinion Call Centre operators and their supervisors must be provided with domestic violence training which instructs them on how and when to deal with allegations of domestic violence and emphasises that where it is not known that the victim is actually safe, and that cannot be ascertained adequately on the telephone, a police patrol should attend.

12.7 The failure by anyone at the SAPOL call centre to bother to inquire as the identity of the perpetrator of the domestic violence allegation if profoundly disturbing. It shows a lack of interest and commitment to the job of policing and keeping South Australians safe. It shows a narrow focus on the immediate task, and a desire merely to get rid of a problem with a minimum of effort. Public safety can only be protected if SAPOL officers take advantage of the information and tools at their disposal when every opportunity presents itself. In this instance, the identification of the perpetrator as Mr Robinson was the essential first step in further inquires on PIMS that would have revealed compelling reasons to take action to prevent potential risks to the public. Such a search would have yielded the information that Mr Robinson was a dangerous man in whom the Deputy Commissioner had shown a particular interest. Surely that would have compelled further action that may have prevented the rampage that Mr Robinson subsequently embarked upon with such terrible consequences for innocent third parties.

12.8 In my opinion the ANCOR system requires, at the very least, that high risk offenders have a dedicated case manager and I intend to make a recommendation to that effect.

The management of high risk offenders requires an intensive and centralised approach.

The process of management should be clear and accountable. The object of preventing harm to others should be paramount.

12.9 The contact by Fiona Beevor to ANCOR should have resulted in further action based on the information available to ANCOR officers. The Child Sex Offenders Registration Act 2006 has as one of its objects the investigation and prosecution of any offences that are committed by an ANCOR offender19 not just child sex offences. The statute under which the ANCOR officers were acting was designed to keep registered child sex offenders under police scrutiny. Once again, this tool that was at the disposal of police was not used. The same narrow focus and lack of interest noted above was exhibited by the ANCOR officers. A further opportunity to prevent the mayhem that ensued was not taken.

13. Recommendations 13.1 Pursuant to Section 25(2) of the Coroners Act 2003 I am empowered to make recommendations that in the opinion of the Court might prevent, or reduce the likelihood of, a recurrence of an event similar to the event that was the subject of the 19 S3(a)(ii)

Inquest. I acknowledge the assistance of Ms Ehrat, Senior Research Officer, Domestic Violence, in the preparation of this finding, and particularly in assisting with the formulation of these recommendations.

13.2 In all of the circumstances I make the following recommendations:

1. That the Commissioner of Police allocate proper resources to ensure that high risk offenders have dedicated case managers and, as far as is practicable, that the same case manager monitor high risk offenders throughout their time under ANCOR;

2. That the Commissioner of Police formally advises ANCOR staff and Officers of their obligations to the protection of children. In particular the requirement to make mandatory notifications of suspected risk, to share information and negotiate with other agencies to effect the safe investigation of those concerns.

3. That the Commissioner of Police ensure that all SAPOL call centre staff and officers should have specific and regular skills training and procedural updates to ensure they have a working knowledge of appropriate responses and their obligations relating to disclosures of domestic violence.

4. Call centre staff who are administrative officers (not members of the police force) should not be allowed to make “cold calls” to victims of domestic violence. Such contacts should only be made by phone by appropriately trained police officers.

5. That the Minister for Correctional Services implements a random saliva testing system based on the system employed by SAPOL for roadside testing of motorists as a supplement to the urinalysis testing presently used in the supervision of high risk parolees.

6. That the Minister for Correctional Services ensures Community Corrections Staff are specifically trained in and cognisant of procedures relating to the disclosure of domestic violence offending by victims. This should include the ability to conduct standard risk assessment and effect relevant referrals including to a Family Safety Framework meeting where high risk is indentified.

Key Words: Death in Custody; Siege In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 14th day of February, 2013.

State Coroner Inquest Number 43/2011 (1100/2009)