Coroner's Finding: HARDING-ROOTS Jeremy Godfrey

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 10th day of June 2014, the 4th, 5th, 6th, 7th, 8th and 13th days of August 2014, the 2nd, 9th, 11th, 22nd and 23rd days of September 2014 and the 24th day of June 2015, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Jeremy Godfrey HardingRoots.

The said Court finds that Jeremy Godfrey Harding-Roots aged 47 years, late of 8 Dienelt Drive, Para Hills West, South Australia died at 5/182 Diagonal Road, Warradale, South Australia on the 24th day of July 2011 as a result of the toxic effects of phosphine. The said Court finds that the circumstances of his death were as follows:

1. Introduction and cause of death 1.1. Jeremy Godfrey Harding-Roots died on 24 July 2011. He was 47 years of age. Mr Harding-Roots died after he was exposed to a lethal level of phosphine gas.

Phosphine gas, which is a highly toxic fumigant, is released when aluminium phosphide reacts with water or is exposed to the air. Aluminium phosphide has the brand name of Fumitoxin. The solid aluminium phosphide is a light coloured powder and comes in tablet form. Aluminium phosphide is registered for use as a pesticide and is widely used for fumigating grain and killing verminous mammals such as rodents. The presence of elevated levels of aluminium in the blood and in the stomach contents at autopsy is a useful marker of aluminium phosphide exposure.

1.2. On the morning of his death, Mr Harding-Roots travelled by taxi from his home at Para Hills West to the Warradale unit occupied by his former girlfriend, Ms Mandy

Rankine. He brought with him a Fumitoxin container which he had stolen from his employer. Ms Rankine and her current partner were on the premises together in bed.

Mr Harding-Roots let himself in with a key that he had retained from his relationship with Ms Rankine. He was wearing a motorcycle helmet and had a metal pole in his possession. He possessed something that appeared to be a spray bottle. He also had the Fumitoxin. The evidence demonstrated that Mr Harding-Roots’ objective was to use the Fumitoxin to take the life of Ms Rankine and her partner, Mr Daniel Neailey, and also to kill himself. Once inside the unit Mr Harding-Roots told Ms Rankine that he was going to kill her and then proceeded to strike her with the pole. Ms Rankine’s partner then engaged Mr Harding-Roots in a fight. She and Mr Neailey managed to escape the unit. The police were called to the premises. They took up a position outside. Mr Harding-Roots remained inside. There then developed something of a siege. It became evident to police that Mr Harding-Roots had fortified himself in the premises and that he was in possession of a toxic substance. He was not going to come out. Police were naturally reluctant to enter the unit to apprehend Mr HardingRoots without first conducting a thorough risk assessment. I was told in evidence, and I accept this, that this siege situation, involving as it did the threatened use by the perpetrator of a toxic substance as a weapon, was unprecedented in Australian police experience. This explains a high level of understandable caution on the part of police.

The evidence is clear that at a time before police ultimately entered the unit with protective clothing, Mr Harding-Roots deliberately deployed the Fumitoxin with a view to taking his own life. He would succumb to the effects of the substance and was ultimately found by police deceased inside the premises. It is suspected that Mr Harding-Roots may not only have inhaled the gas, but also consumed some of the aluminium phosphide. Powder was found on and around his mouth.

1.3. Before embarking upon a discussion of the circumstances surrounding Mr HardingRoots’ death it is necessary to say something about the post-mortem examination of his remains. The examination was conducted by Dr Neil Langlois who is a forensic pathologist at Forensic Science South Australia. Dr Langlois post mortem report was tendered to the Inquest. Dr Langlois reports that potentially toxic levels of phosphine gas were recorded at the premises where Mr Harding-Roots’ body was located by police. When his body was examined in the mortuary it still exhibited evidence of exposure to phosphine. Phosphine gas was detected when the body bag that contained Mr Harding-Roots was opened. Although toxicological analysis is not available

specifically for phosphine, analysis did reveal a high level of aluminium in the stomach contents of Mr Harding-Roots. Aluminium is a component of aluminium phosphide. Aluminium was also detected in Mr Harding-Roots’ pulmonary blood.

Dr Langlois reports that the finding of aluminium in the stomach content is a nonspecific finding as aluminium can be a component of medication taken for indigestion. However, in the absence of any other anatomical cause of death, and given the exposure to a potentially toxic atmosphere of phosphine in the house in which Mr Harding-Roots was located, death in Dr Langlois’ opinion can be attributed to the toxic effects of phosphine1.

1.4. Mr Harding-Roots had no natural disease, either diagnosed in life or detected at post mortem.

1.5. I find that the cause of Mr Harding-Roots’ death was the toxic effects of phosphine.

1.6. The only other anatomical findings of significance at post-mortem were that Mr Harding-Roots had fractures of the left and right superior horns of the thyroid cartilage with local haemorrhage as well as bruising of tissues of the neck. These injuries are in keeping with pressure having been applied to the neck in the course of a violent altercation.

1.7. Toxicological analysis of Mr Harding-Roots’ bloodstream also revealed non-toxic concentrations of the benzodiazepines, oxazepam and temazepam. These drugs are prescribed for anxiety disorders. They had been prescribed for Mr Harding-Roots2.

No other drugs such as alcohol, amphetamines, cannabinoids, cocaine and morphine were detected in his blood.

2. Background 2.1. At the time of Mr Harding-Roots’ death he was still married to, but separated from, his wife Lynn Harding-Roots. They were married in 2002 and had been together for approximately 8 years prior to their marriage. Despite their separation they maintained regular contact with each other. Ms Harding-Roots provided two statements to police3. She describes a significant element of negativity about her husband’s frame of mind during their marriage. She asserts that during their marriage 1 Exhibit C2a 2 Exhibit C23, Statement of Dr Jaber and Exhibit C24, Statement of Dr Tucker 3 Exhibits C16a and C16b

her husband would habitually state that he was not worth anything, had nothing to live for and that he was going to commit suicide, although he did not attempt to do so at any time.

2.2. Mr Harding-Roots and his wife lived in premises at Para Hills West. There were no children of the marriage. In early 2009 Mr Harding-Roots would stay away from home on weekends and it became apparent to Ms Harding-Roots that he had developed a relationship with the woman to whom I have earlier referred, Ms Mandy Rankine. At that time Ms Rankine was a cleaner at the Morphettville Racecourse where Mr Harding-Roots also worked. There were occasions when Ms Rankine stayed with her niece at the home occupied by the Harding-Roots at Para Hills West.

2.3. Ms Harding-Roots states that in April 2010 she moved out of the Para Hills West marital home. Mr Harding-Roots remained at that premises and would continue to reside there until his death. Ms Harding-Roots and Mr Harding-Roots had telephone contact on a weekly basis. Ms Harding-Roots asserts that Mr Harding-Roots maintained his negative attitude and was also preoccupied with monetary matters. At one point she became aware that Mr Harding-Roots’ second cousin had moved into the Para Hills West premises and also came to the realisation that Ms Rankine was attending the premises on a regular basis.

2.4. On Thursday 21 July 2011, which was three days prior to Mr Harding-Roots’ death, Ms Harding-Roots spoke to Mr Harding-Roots on the phone. As will be seen later in these findings, by this time the relationship between Mr Harding-Roots and Ms Rankine had also concluded, but that Mr Harding-Roots would not accept this. In this phone conversation Mr Harding-Roots revealed to his wife that he had paid off the house loan and had taken out house and car insurance in their joint names. He also said that he had seen a psychiatrist and had been seeing a doctor twice a week.

Mr Harding-Roots cried throughout the phone call. He revealed that he was on antidepressants. Mr Harding-Roots told Ms Harding-Roots that he wanted her back to which she gave a negative response. Mr Harding-Roots appears to have been in emotional turmoil at this time, although he at least may have possessed enough insight to have sought professional help. In the phone conversation with his wife Mr Harding-Roots mentioned an incident involving Ms Rankine at her premises that had culminated in the police having to be called. In a context that I will mention in due course this incident was the subject of much evidence during the course of this

Inquest. It was an incident that Mr Harding-Roots would also mention in a suicide note that he would ultimately leave for a relative. During the course of the Inquest this occurrence came to be referred to as the 18 June incident and I will from here on refer to it in the same manner. Throughout this phone conversation with Ms HardingRoots his demeanour remained emotional and hysterical. He told his wife that he had nothing to live for, that he was going to commit suicide and that he intended to exact revenge on Ms Rankine whom he referred to as ‘the fucking slut’. Ms Harding-Roots described his demeanour in this context as hysterically vicious. This was the last time that Ms Harding-Roots spoke to her estranged husband. On the following Sunday, 24 July 2011, Ms Harding-Roots became aware that Mr Harding-Roots had that day died at Ms Rankine’s premises at Warradale. There is no evidence that Ms Harding-Roots contacted the authorities in respect of any threat that Mr Harding-Roots had made in respect of either his own life or in respect of the life or wellbeing of Ms Rankine.

2.5. Ms Rankine also provided a number of statements4 to police and gave oral evidence at the Inquest on no less than three occasions separated by a number of weeks. Ms Rankine’s, at times, unhelpful demeanour in the witness box did not assist in assessing her overall credibility. I was reluctant to accept her evidence concerning matters in which she was contradicted unless it was corroborated by other evidence.

On the other hand, I found her partner, Mr Daniel Neailey to be a straightforward and helpful witness who did his best to impart the truth as he believed it to be.

2.6. In her evidence Ms Rankine confirmed that she had developed a relationship with Mr Harding-Roots that had culminated when she broke it off. Mr Harding-Roots had found the rejection extremely difficult to accept, which was naturally complicated by the fact that Ms Rankine had developed a new relationship with another man. Mr Harding-Roots’ own intrinsic emotional turmoil clearly did not help in the process of acceptance. He indicated by way of text messages to Ms Rankine thoughts of selfharm and suicide. On 18 June 2011 he forcefully entered Ms Rankine’s unit at Warradale against her wishes and took her car keys (the 18 June incident). In mid July it became evident to Ms Rankine that he was virtually stalking her and Mr Neailey, and in respect of one incident had passed himself off as a police officer, a criminal offence that can carry imprisonment. Both of these matters were reported to police who took no action.

4 Exhibits C4a, C4b, C4c and C4d

2.7. In the period prior to his death Mr Harding-Roots had been seeking medical and psychiatric assistance. Although he had been placed on antidepressant medication in respect of depression and anxiety, he gave no hint to his medical practitioners that he was at risk of taking his own life or was at risk of harming any other person.

Nevertheless, it is apparent that many individuals, including Ms Rankine, Ms Lynn Harding-Roots, Mr Harding-Roots’ medical practitioners as well as members of Mr Harding-Roots’ family who resided in the United Kingdom and with whom he had recent contact, had concluded that Mr Harding-Roots’ frame of mind was anything but stable and that he was depressed, anxious and unpredictable.

2.8. Mr Harding-Roots’ police record consisted of a conviction for common assault in the Elizabeth Magistrates Court in 1987 for which he was placed on a bond. However, as indicated earlier, in the weeks prior to his death his behaviour in respect of Ms Rankine and her partner Mr Neailey had twice come to the attention of police.

The two incidents to which I have referred had formed the subject of police ancillary reports that are designed to record incidents in respect of individuals where no criminal offence has been committed or disclosed, but where it is necessary for a written record to be made for the sake of police intelligence. These records were kept on a SAPOL database known as the Police Information Management System (PIMS).

However, as will become clear, the incidents that were said to involve behaviour on the part of Mr Harding-Roots towards Ms Rankine and Mr Neailey actually involved the commission of offences in respect of which police General Orders required the compilation and filing of a police incident report (PIR). The compilation and filing of a PIR required investigatory action on the part of police. In the event no such action ever occurred.

2.9. It is apparent from Mr Harding-Roots’ behaviour that his determination to end his own life was generated, or became more acute, following the mid July 2011 incident in which he had impersonated a police officer in what appears to have been a quest to stalk Ms Rankine. On 18 July 2011 Mr Harding-Roots telephoned Ivan Butler Funerals in Klemzig to arrange a prepaid funeral. The following day he again phoned Ivan Butler Funerals and informed the funeral director that he had organised a bank cheque for $5,500 to pay for the funeral and arranged a meeting for the following day.

On 20 July 2011 the funeral director attended at Mr Harding-Roots’ residence where Mr Harding-Roots signed the necessary documentation, paid for the funeral and

informed the funeral director that he had a terminal illness and was expected to live for only a matter of weeks to months. In the days prior to his death Mr Harding-Roots stole a canister of Fumitoxin from his workplace. This was confirmed by him in a suicide letter addressed to SAPOL that was located after his death. On 21 July 2011 Mr Harding-Roots was seen to have removed and photocopied the label of a Fumitoxin canister. He made light of this by saying that he was doing this in order to play a joke on a housemate. This excuse apparently was accepted. It was on the same day that Mr Harding-Roots attended at the office of the RAA in Modbury and added his estranged wife to his house and car insurance policies. As seen, he would subsequently inform Ms Harding-Roots about that. He told the RAA staff member that he was dying and wanted to get his affairs in order. Mr Harding-Roots paid the sum of $1,400 in cash for the policy renewals. Mr Harding-Roots also placed a sum of $5,000 in cash in five separate envelopes in Ms Harding-Roots’ letterbox. It is not known exactly when this took place, but it is fair to infer that it took place very close to the day of Mr Harding-Roots’ death. None of this activity was known to police at the time at which it occurred.

2.10. Mr Harding-Roots left notes and letters that make it plain that his actions on the morning of Sunday 24 July 2011 were intended to end his own life. In my view the circumstances are such that he probably desired and intended to end the lives of Ms Rankine and Mr Neailey as well.

2.11. In the opinion of the Court this was a death in custody. Section 21(1)(a) of the Coroners Act 2003 mandates this Court to conduct an Inquest into the cause and circumstances of a death in custody. Although no apprehension of Mr Harding-Roots had taken place on the day in question, for some period prior to his death Mr HardingRoots had been confined by police to the premises at Warradale. It is clear that the objective of police was to apprehend him at the first available opportunity. For those reasons in my opinion Mr Harding-Roots at the time of his death was in custody as contemplated by the Coroners Act 2003. Accordingly, this Inquest was mandatory.

2.12. A number of issues were examined during the course of this Inquest. They included: Whether the police response to the incident on 24 July 2011 in which Mr Harding-  Roots died was adequate, and in particular whether earlier entry into the premises and intervention could have prevented Mr Harding-Roots’ death;

Whether appropriate police action had taken place in respect of earlier incidents  involving, or allegedly involving, behaviour on the part of Mr Harding-Roots; Whether earlier intervention by police in respect of behaviour evinced by  Mr Harding-Roots or allegedly evinced by him in the period prior to his death could have prevented his death, and in particular have prevented the incident of 24 July 2011.

3. Ms Rankine’s relationship with Mr Harding-Roots 3.1. I have already referred to the fact that Mr Harding-Roots was married to Ms Lynn Harding-Roots and that there was a separation between them that involved Mr Harding-Roots remaining in the marital premises at Para Hills West. Ms Rankine told the Court that she met Mr Harding-Roots when she was a cleaner at the Morphettville Racecourse. Mr Harding-Roots worked as a security officer there on Saturdays. Ms Rankine’s relationship with Mr Harding-Roots did not involve cohabitation except to the extent that according to Ms Rankine she would spend the nights at Mr Harding-Roots’ premises between Thursdays and Sundays. They conducted their relationship over a period that was not precisely established in the evidence but which appears to have exceeded 12 months. I was not satisfied that this relationship involved Ms Rankine and Mr Harding-Roots as ‘domestic partners’ as contemplated within the SAPOL General Orders – Domestic Violence as it existed in

4. Ms Rankine provided a number of statements to the police and gave oral evidence at the Inquest. She explained the breakdown of the relationship. In her original statement to police, taken on the day of Mr Harding-Roots’ death, she said that she broke the relationship off because Mr Harding-Roots had been experiencing depression and had exhibited nasty behaviour towards her. She had urged Mr Harding-Roots to seek help in relation to his difficulties but he refused to admit that he had a problem. However, it is apparent that ultimately Mr Harding-Roots did seek some help and was placed on antidepressants. Alcohol and drugs do not appear to have been features of Mr Harding-Roots’ presentation. Ms Rankine spoke of Mr Harding-Roots’ mood swings and negative talk which was all in keeping with his wife’s description of him. Mr Harding-Roots appeared to demonstrate a preoccupation with the death of his mother. According to Ms Rankine, the only physical altercation of any significance between them was an occasion when, in frustration, he punched her right thigh, an impact which did not cause any injury or

bruising. Ms Rankine said that at no time during their relationship did Mr HardingRoots threaten to hurt her, nor did he say anything towards her that had made her think that he might assault her. She did say, however, that there had been occasions when Mr Harding-Roots threatened to harm himself. She did not see any need to report Mr Harding-Roots to the police until the 18 June incident when he entered her home and took her car keys. I gained a distinct impression from Ms Rankine’s evidence that she had been very fond of Mr Harding-Roots despite his more negative personal traits.

3.2. When Ms Rankine broke off the relationship, Mr Harding-Roots did not exhibit any inclination to accept that. Ms Rankine commenced a relationship with Mr Daniel Neailey, whom she had also met through her work, sometime before the June long weekend in 2011. Mr Harding-Roots and Mr Neailey were not previously known to each other.

3.3. When the relationship ended Ms Rankine took her belongings out of Mr HardingRoots’ premises at Para Hills West except that she had left a set of keys at his premises that she believed Mr Harding-Roots had no knowledge of. In addition, he had retained another set of keys that Ms Rankine suggests was given to him to enable him to enter her Warradale unit and shower for his employment purposes. This was to save him having to travel to his own home at Para Hills West. Evidence about Mr Harding-Roots’ retention of Ms Rankine’s house keys was somewhat confusing.

This was particularly so in relation to the number of sets of keys that Mr HardingRoots may have had access to or knew about, and also in respect of the reason why Mr Harding-Roots possessed her keys in the first instance and why he retained them after the cessation of their relationship. Ms Rankine would ultimately tell this Court that there was the incident of 18 June 2011, some weeks before Mr Harding-Roots’ death, in which, against her will, he let himself into her unit with a retained set of her keys. It is also apparent that he also had access to another of her keys which he would use to enter her unit on the day of his death. In any event there is no doubt in my mind that Ms Rankine was of the firm view that by June 2011 her relationship with Mr Harding-Roots was well and truly over. Notwithstanding this, according to Ms Rankine Mr Harding-Roots attempted to contact her on several occasions by text messages and phone calls. She asserted that a number of the text messages suggested that he was going to kill himself and that he did not want to live any longer. She said that she ignored most of these attempts to contact her, although she said that she did

occasionally text back saying things such as ‘don’t be stupid’ or ‘it’s not worth it’.

She said that in the months of March and April 2011 she was averaging about ten communications per week. There were calls in which he said that he missed her and how much he wanted her back. In the event police would be able to view some of the text messages that Ms Rankine received.

4. Mr Harding-Roots enters Ms Rankine’s unit against her will – the 18 June 2011 incident

4.1. On Saturday 18 June 2011 Mr Harding-Roots drove to Ms Rankine’s unit at Warradale, forced his way in and took her car keys. Although this matter was reported to police on that day, no statement would be taken from Ms Rankine about this incident until 24 July 2011, the day of Mr Harding-Roots’ death. This statement of some ten pages5 was only prompted by Mr Harding-Roots’ death. The statement deals with the incident of that day as well as other matters concerning her relationship with Mr Harding-Roots. Although it does include reference to the 18 June incident 2011 and other matters, it is by no means a comprehensive statement. I drew no adverse conclusion as to Ms Rankine’s credibility based on alleged imperfect detail in this statement. The detail involved in the 18 June incident was the subject of close questioning of Ms Rankine when she gave evidence in the witness box. In the event police would take no action against Mr Harding-Roots in respect of this incident.

4.2. Ms Rankine told the Court that on the evening of 18 June 2011 she was home alone at her unit at Warradale. She was speaking on the telephone to a friend by the name of Debbie Smith when she observed Mr Harding-Roots drive past. She and Ms Smith remained on the phone and it was agreed between them that she would pretend that she was not home. Mr Harding-Roots eventually came to the front door. He knocked on the door and the windows. Ms Rankine ignored this. In due course she heard a key enter the lock of her screen door. The precise circumstances in which the solid inner door then came to be unlocked and partially opened were not entirely clear from her evidence, but her evidence was plain that Mr Harding-Roots had used a key at least to open the screen door and that she did not welcome this intrusion. I have accepted that evidence. As Mr Harding-Roots was entering, Ms Rankine went to the door and told him to go away. As well, she demanded her key back. Ms Rankine was 5 Exhibit C4a

endeavouring to stop him from coming in, but I have concluded that at the same time she was just as determined to get her key back. To this end she put her hand out for Mr Harding-Roots to put the key in. By then the inner solid door was open far enough for her to get her hand through. He gave her the key. I accept that Ms Rankine was pushing against that door in order to prevent Mr Harding-Roots’ complete entry. Mr Harding-Roots then forcefully pushed the inner door inside which resulted in Ms Rankine falling backwards onto a lounge chair. She was not hurt. All the while it appears that Ms Rankine was still on the telephone to Ms Smith. Ms Smith would tell the Court that from what she heard she could determine that Mr Harding-Roots was forcefully entering the premises. When Mr Harding-Roots entered the unit he said that he wanted to speak to her. He was yelling at her but was not aggressive towards her apart from that. At one stage he removed a cigarette from her pack and opened the fridge. Ms Rankine was screaming at him to get out of her house as she did not want him in there. She herself walked out the front door and spoke to a neighbour whose attention had been drawn to the incident. There was some discussion between Ms Rankine and her neighbour about calling the police.

Mr Harding-Roots then came out of the unit and said words to the effect that there was no need to do this as he was leaving. He then left. He had only been there for a few minutes. Ms Rankine then went back into her unit. It is clear that Ms Rankine telephoned her partner Mr Neailey who then left his place of work at Harbour Town on Tapleys Hill Road and drove to Ms Rankine’s premises. At one point after Mr Harding-Roots left her unit Ms Rankine received a telephone call from him. He said words to the effect that he hoped that Ms Rankine had a spare set of keys. He then hung up. Ms Rankine checked her belongings and came to the realisation that Mr Harding-Roots had taken a set of her keys that included the key to her motor vehicle. Later that evening these keys would be located in her letter box.

4.3. Ms Rankine’s partner Mr Neailey arrived at the unit. Mr Neailey then telephoned police to advise them of the incident. Mr Neailey told the Court that when he received the call from Ms Rankine he could tell that she was stressed. She said that Mr Harding-Roots had forced his way into her unit. As well, she told Mr Neailey that before Mr Harding-Roots did this she had pretended that she was not home. She told him that she had heard the screen door open. She told him that he had forced his way

in and had knocked her over causing her to fall backwards onto an arm chair. He was also aware that her keys had been taken by Mr Harding-Roots when he left.

4.4. The phone call that was made to police by Mr Neailey is recorded in police computerised records as having occurred at 7:35pm. There is an archived record of this which constitutes a summary of this communication6. It is called a CAD report.

The communication was recorded as follows: 'RP: Daniel Neailey (irrelevant) states that his girlfriend is being harassed … girlfriend is Mandy RANKINE … now talking to her … at 1845 her ex partner Jeremy ROOTS pushed his way into her unit … she was knocked to the ground … she ran out and waited outside … ml called her and said that he has taken her car keys … said she won’t get them back unless she talks to him … complt was shaken by this … his home address is 8 Dienelt Dr, Para Hills … Ms Lower has now left (MTF)' It will be observed that Mr Neailey is recorded as the reporting person. The salient features of the information conveyed to and recorded by police was that Ms Rankine had been harassed and that Mr Harding-ROOTS had pushed his way into her unit and that she was knocked to the ground. Mr Neailey reported that he had then called Ms Rankine who said that he had taken her keys and that she would not get them back unless she spoke to him. He complained to police that Ms Rankine had been shaken by this. The record does not contain any detail as to how Mr Harding-Roots had managed to push his way into the unit, and in particular whether he had initially opened the door with a key. It also mentions nothing about Ms Rankine having been pushed back onto a chair; rather it speaks of her being knocked to the ground.

Clearly, however, the message within this information was that Mr Harding-Roots had entered the unit without Ms Rankine’s consent, that she had offered some resistance to that and had been knocked over in the process. The flavour of this communication is that anything that Mr Harding-Roots had done had been done against her will, including of course the entry into her premises.

4.5. There appears to have been a lapse of time between the incident involving Mr Harding-Roots and the telephone communication made by Mr Neailey to police.

In her various statements Ms Rankine indicated that Mr Harding-Roots had phoned her about having taken her keys approximately 30 minutes after he had left the flat. It was suggested to Ms Rankine in cross-examination that the matter would not have been reported to police but for the fact that Mr Harding-Roots had telephoned her to 6 Exhibit C97b

say that he had taken her keys and that she wanted them back. Ms Rankine demonstrated considerable reluctance to acknowledge that suggestion. Mr Neailey stated that he would have telephoned the police to report the incident regardless of the fact that Ms Rankine’s keys had been taken. I mention this issue because the police officers who responded to the complaint told the Court that they formed an impression that Ms Rankine merely wanted police to assist in having her keys returned to her and wanted no further action taken against Mr Harding-Roots.

4.6. The police tasking was assigned to a patrol from the Sturt local service area. It comprised Senior Constable Lynda Crisp and Probationary Constable Andrew Schumacher. Ms Crisp was the senior police officer of the two. The police vehicle of Ms Crisp and Mr Schumacher had computerised access to the CAD report that I have set out above. Although neither of the officers would have had access to a hard copy of the communication record, I am certain that, depending on who was driving the vehicle, Ms Crisp and Mr Schumacher either had read the communication for themselves, or had it read out to him or her. They would have been familiar with its contents before they came to interact with Ms Rankine and Mr Neailey. Accordingly, both officers would have had a clear understanding that Mr Harding-Roots had allegedly entered the complainant’s unit against her will, had done so using physical force against her and that the complainant had been allegedly knocked over. As well there was the question of the missing car keys.

4.7. Before dealing with the interaction between Ms Rankine, Mr Neailey and the two police officers, it is as well to examine the evidence concerning the incident involving Mr Harding-Roots that is independent of Ms Rankine’s version of events. I have already referred to Ms Debbie Smith who was on the other end of the phone when Ms Rankine’s unit was entered by Mr Harding-Roots. Ms Smith gave general evidence to the effect that Ms Rankine was describing the incident as it unfolded. Ms Rankine’s description of those events included assertions from which Ms Smith could reasonably have concluded that Mr Harding-Roots had entered Ms Rankine’s unit without her consent and in doing so had opened the door forcefully causing Ms Rankine to fall backwards. However, if there was any doubt about what had taken place it is confirmed by Mr Harding-Roots’ own writings as contained in a letter that would be written by him in preparation of his death. The letter was written to his cousin Jon North who was at the time residing with him at the Para Hills West

address7. In that letter Mr Harding-Roots referred to the 18 June incident. He said that ‘the Mandy thing’ had been on his mind ever since that date. In the letter Mr Harding-Roots said that he had run out of smokes. He thought he would go and see Ms Rankine to talk to her and to obtain some cigarettes from her. He had seen that her car was in the drive and so he at first attempted to call her. She had not answered. He alighted from his vehicle and walked up the drive. He noticed that there were no lights on in the unit. This of course would be in keeping with Ms Rankine’s efforts to create the impression that nobody was home. In the letter Mr Harding-Roots acknowledges that at the time he had Ms Rankine’s keys.

Believing that she was not home he let himself in. This corroborates Ms Rankine when she told the Court that Mr Harding-Roots used a key to at least open the screen door. He states in the letter that when he did this Ms Rankine pushed the door onto him and that he then, to use his words, ‘pushed my way in’. He acknowledges that as this was taking place Ms Rankine was repeatedly shouting at him to get out and at the same time was on the telephone. He acknowledges that he took cigarettes and her car keys which he then put in her letter box. He said that he had not expected Ms Rankine to call the police. There is no reason to suppose that in this letter Mr Harding-Roots, in contemplation of his own imminent death, had stated anything about the 18 June incident that was not true. I give full weight to Mr Harding-Roots’ admissions as contained within the letter to Mr North.

4.8. Accordingly I find that on 18 June 2011 Mr Harding-Roots, without the permission of the occupant Ms Rankine, unlocked and opened the screen door of the unit with a key.

I find that Ms Rankine resisted his entry into the unit by pushing against the inner solid door. I find that Mr Harding-Roots overcame that resistance by forcing the inner door open. I also find that in the process of his overcoming Ms Rankine’s resistance he caused Ms Rankine to fall backwards onto a chair. All the while Ms Rankine was yelling at Mr Harding-Roots for him to get out. I find that Mr Harding-Roots entered the unit without Ms Rankine’s permission and that he well knew that. Ms Rankine was not consenting to his entry of the premises. Mr HardingRoots had no lawful reason for entering the premises against Ms Rankine’s will. I find that Mr Harding-Roots, once in the premises, found a set of Ms Rankine’s keys that included the keys to her car and that he left the unit with them. I further find that Mr Harding-Roots committed an offence of criminal trespass in a place of residence 7 Exhibit C82e, Miscellaneous Document 44

contrary to section 170A of the Criminal Law Consolidation Act 1935. Such an offence in its basic form can carry imprisonment.

4.9. Ms Rankine told the Court on her oath that once the two police officers, Ms Crisp and Mr Schumacher, attended her unit she told them what had taken place. She testified that she told the police ‘everything that had happened’ including that Mr HardingRoots had a key and had pushed his way in8. She told them that he had forced open the door and pushed her back onto the lounge9. She also told them that when Mr Harding-Roots left her unit he had taken her keys. Ms Rankine maintained that she explained to police how it was that Mr Harding-Roots still had her key. Save and except for the allegation that Mr Harding-Roots had made off with her car keys, the two police officers denied that this level of detail had been imparted to them. I will come to what the police officers told the Court in a moment, but it was suggested to Ms Rankine in cross-examination by Ms De Palma of counsel for the Commissioner for Police that in reality she had no real recollection of what she had told the police and that her evidence as to what she had told them was a reconstruction. Ms Rankine rejected this suggestion. When it was put to her in cross-examination that she had not told police that Mr Harding-Roots had pushed his way in through the door or had pushed her causing her to fall back onto a couch, she said that she had in fact told the police all of that10. Further, it was suggested to her that the only reason the police were phoned in respect of the incident was that she wanted to enlist the help of police to have her keys returned11. She denied the suggestion that she had absolutely no intention of ringing the police until she made the discovery about her keys. But it is a fact that the police were not telephoned at any time prior to the discovery that the keys were missing.

4.10. As indicated earlier Ms Rankine made a number of statements to the police. These statements were made to police on 24 July 201112, 25 September 201113, 15 October 201114 and 21 May 201215. In two of those statements, namely that of 24 July 2011 and 21 May 2012, Ms Rankine gave an account of the 18 June incident. The first of those statements, which was given on 24 July 2011, the day of Mr Harding-Roots’ 8 Transcript, page 40 9 Transcript, page 41 10 Transcript, page 354 11 Transcript, page 361 12 Exhibit C4a 13 Exhibit C4b 14 Exhibit C4c 15 Exhibit C4d

death, covered a number of topics. In that statement she said that she could hear Mr Harding-Roots using a key to enter through the front door. She also stated that she was holding the door locked but that he was stronger than she and that he managed to open the door notwithstanding her resistance. She said that he pushed her backwards out of the way and walked in. She mentioned the screaming to get out of her premises. In that statement Ms Rankine also described her interaction with the police who had attended and the matter of Mr Harding-Roots having taken her keys.

There was nothing in that account regarding Ms Rankine’s retrieving the key that Mr Harding-Roots had used to open the door. In Ms Rankine’s statement of 21 May 2012 she said that, as she had said in her original statement, the police were contacted about half an hour after Mr Harding-Roots had left, and added to this ‘once I had realised Jeremy had taken my house and car keys’. The flavour of that statement tends to suggest that the decision to call the police was prompted by the fact that Mr Harding-Roots had taken her car keys. This lends support to the suggestion that police may not have been contacted otherwise. She did say in this statement that Mr Harding-Roots had forced his way into her unit.

4.11. Mr Daniel Neailey was called to give oral evidence. Mr Neailey had also given a statement to police on 24 July 2011, the day of Mr Harding-Roots’ death16. This statement gives an account about the 18 June incident of one paragraph in length. Mr Neailey describes having been called by Ms Rankine who told him that Mr HardingRoots had forced his way into her unit and had assaulted her in the unit. There is no further detail provided in the statement. When Mr Neailey gave oral evidence he told the Court that he was the person who rang police and that he had done so from Ms Rankine’s unit. When asked as to his belief as to how Mr Harding-Roots had entered the premises, he said that Ms Rankine had told him that she had first heard the screen door opening and that she had held the handle on the main wooden door and was screaming at him to go away. There was some discussion about him returning her keys to her and that when she went to open the door a little for him to pass the keys through, he forced his way in and knocked her over17. Mr Neailey said that Ms Rankine had given him to understand that Ms Rankine herself had unlocked the door in order to allow Mr Harding-Roots to pass the keys through to her. I do not believe that Ms Rankine had a motive to be anything less than frank with Mr Neailey 16 Exhibit C5a 17 Transcript, page 417

about the fact that Mr Harding-Roots had retained a set of her unit keys despite the fact that the relationship had ended. Mr Neailey believed that Ms Rankine had told him about her having been forced backwards onto an armchair and that Ms Rankine had told him about this before the police arrived. He gave an account of what he told police on the phone that is not inconsistent with the contents of the CAD report set out earlier in these findings. It is an account that is broadly consistent with what he says he had been told by Ms Rankine at a time before police arrived. I have no hesitation in finding that Mr Neailey told the Court the truth about what Ms Rankine had told him about the incident. I find that before police arrived at her unit she had told Mr Neailey all of the above detail.

4.12. When police arrived Mr Neailey saw them pull up and so he approached them outside the unit. He said that he ‘just briefly told them what has happened’18. When asked for detail he said that by then he and Ms Rankine had discovered that Ms Rankine’s keys were missing. He said to police that Mr Harding-Roots had forced his way into the unit and that her keys were now missing. Asked in evidence as to how much of what Ms Rankine had told him that he in turn had imparted to police, he said ‘I pretty much told them most of it but in a brief way, all of it’19. Mr Neailey was somewhat uncertain about what exactly he himself had told police, but told the Court that he was present when Ms Rankine spoke to police and that she gave an account that aligned with what she had told him. He testified that as far as he could recall she did not omit any detail20. However, he said: 'I can’t say 100% certain but I’m pretty sure she described what happened and also that she discovered that her keys had been taken.' 21 Mr Neailey’s evidence was that he did not detect any difference in the account that Ms Rankine gave police from what she had told him. When pressed as to precisely what was said, Mr Neailey was somewhat uncertain. For instance, he was not certain as to whether there had been conversation about the keys and how Mr Harding-Roots had entered the unit22. It was put to Mr Neailey in cross-examination by Ms De Palma whether it was possible that what Ms Rankine had in fact told police was that she had been speaking with Mr Harding-Roots through the screen door as she did not want him inside, but that he simply opened it and walked in. Mr Neailey rejected that as a 18 Transcript, page 413 19 Transcript, page 418 20 Transcript, page 419 21 Transcript, page 420 22 Transcript, pages 422-423

possibility. He said that it was wrong to suggest that Ms Rankine had told police that Mr Harding-Roots had walked in; he had forced his way in23. Mr Neailey rejected the suggestion by Ms Shaw of counsel for Senior Constable Crisp that originally he had no intention of calling the police and only did so once he knew Ms Rankine’s keys were missing. He said that he still would have phoned them regardless24. He did acknowledge that the issue of the missing keys was the ‘main concern’, as well as others25.

4.13. As things were to transpire, Ms Crisp spoke to Mr Harding-Roots on the telephone and it was established that Mr Harding-Roots had deposited Ms Rankine’s car keys in her letterbox. Mr Schumacher found the keys at that location. In the course of the interaction between police and Mr Harding-Roots, the details of which I will come to in a moment, there was a further revelation about Mr Harding-Roots’ frame of mind that is the subject of dispute between Ms Rankine and Mr Neailey on the one hand and the two officers on the other. I will deal with that issue separately, but it is as well to deal with what the two officers assert was said to them about the manner in which Mr Harding-Roots had entered the premises and whether their response to that issue had been an appropriate police response.

4.14. Both Ms Crisp and Mr Schumacher gave oral evidence in the Inquest. I have already indicated that there is no suggestion that either officer was unaware of the contents of the CAD report that recorded the information that Mr Neailey had imparted to Police Communications on the phone. Yet both officers denied that when Ms Rankine was spoken to in person she described a forceful entry by Harding-Roots or said that she had been knocked over. Mr Schumacher made no note in respect of the incident, contemporaneous or otherwise. Ms Crisp’s contemporaneous notebook entry26 is not helpful in that it records nothing of significance in relation to the circumstances in which Mr Harding-Roots came to be at the premises and how he entered it. After the police attendance, an account of what took place at the residence would be entered on to the CAD report. It too contains nothing about Mr Harding-Roots’ alleged method of entry. In due course Ms Crisp would compile a police ancillary report. Again, there is nothing about the method of entry. The precise occasion on which this report was compiled is by no means clear. The hard copy PD345 ancillary report 23 Transcript, page 439 24 Transcript, pages 453-454 25 Transcript, page 454 26 Exhibit C95d

materialised on 15 July 2011 which was nearly a month after the 18 June incident. A further incident allegedly involving Mr Harding-Roots and which had been reported to police by Ms Rankine had taken place the day before on 14 July 2011. It was this incident that prompted the creation of the ancillary report relating to the 18 June incident. The ancillary report would not be posted to the SAPOL PIMS system until 16 August 2011, some weeks after Mr Harding-Roots’ death. I should mention at this point that it is common ground that whatever the police officers were told by Ms Rankine after the 18 June incident, the creation and filing of a SAPOL ancillary report was an inadequate response and that a SAPOL PIR, reporting the commission of an offence, namely a criminal trespass, ought to have been filed and uploaded onto the system and then acted upon by way of an appropriate investigation. I return to the contents of Ms Crisp’s notebook entry, the CAD entry and the ancillary report in due course.

4.15. Senior Constable Lynda Crisp made two written statements in respect of Mr HardingRoots. The first statement is dated 6 August 201127. The second statement is dated 19 May 201228. In addition, Ms Crisp was interviewed by officers of the SAPOL Internal Investigation Section on 18 July 201329. Ms Crisp gave oral evidence at the Inquest on two separate occasions separated by a number of weeks. The first of Ms Crisp’s witness statements was made sometime after the compilation of her ancillary report, but at a time prior to its posting on PIMS which took place on 16 August 2011.

In her statement of 6 August 2011 Ms Crisp indicated that Ms Rankine had stated that she had been speaking to Mr Harding-Roots through the screen door, that he had opened it and had walked in. Ms Crisp stated that Ms Rankine had said that he had returned his spare key to her, but on leaving had taken a bunch of keys that included her car key. Ms Crisp’s statement asserts that Ms Rankine did not make any allegations of assault. The statement then goes on to describe attempts to speak on the telephone with Mr Harding-Roots which culminated in Ms Crisp herself speaking to him. Her statement indicates that she asked Mr Harding-Roots to promptly return the keys to avoid any police action being taken in relation to theft. Mr Harding-Roots had continually stated that he just wanted to speak to Ms Rankine. Eventually Mr Harding-Roots told Ms Crisp that the keys were in the letterbox. Thereafter Mr Schumacher then located them in the letterbox. Ms Crisp told Mr Harding-Roots 27 Exhibit C95a 28 Exhibit C95b 29 Exhibit C95c, Transcript of Interview

to stop calling Ms Rankine and to cease harassing her in the future. She states that she suggested to Ms Rankine that she could change her mobile phone number or contact her phone provider to have Mr Harding-Roots’ number blocked.

4.16. In Ms Crisp’s statement of 19 May 2012 she stated that Ms Rankine had told her that Mr Harding-Roots had attended at her unit and had entered uninvited. There is also reference to the keys and the conversation with Mr Harding-Roots in which he revealed that the keys were in the letterbox. She asserts that Ms Rankine was thankful for their assistance in recovering the keys. Ms Crisp states: 'RANKINE was simply intent on getting the keys back HARDING-ROOTS had taken and did not furnish any information to warrant a police incident report in relation to how HARDING-ROOTS had entered her residence. Consequently no police incident was raised and therefore a PD207a (no further action) was not obtained from her.

RANKINE was advised to contact police if HARDING-ROOTS re-attended at her residence in the future.' 30

4.17. It will be observed that Ms Crisp’s two witness statements do not specifically deal with the issue as to whether or not Mr Harding-Roots had used a key to unlock the screen door to Ms Rankine’s unit, nor the issue as to whether or not Mr HardingRoots had used force to enter the premises or had caused Ms Rankine to fall after overcoming her physical resistance to his entry. Nor does either statement contain anything in relation to whether or not Ms Crisp had questioned Ms Rankine or indeed Mr Neailey about the contents of the CAD report that had been based upon information imparted by Mr Neailey in his call to police.

4.18. In her interview with SAPOL Internal Investigation Section, Ms Crisp reiterated that her understanding had been that Mr Harding-Roots had opened the door and had walked in uninvited. She said that Ms Rankine never mentioned that Mr HardingRoots pushed the door open and that she had fallen over. When asked as to whether Ms Crisp had ‘qualified’ that with Ms Rankine she said that she imagined that she would have done so, but that Ms Rankine had not said anything about being pushed over or assaulted. She simply said that Mr Harding-Roots had come in, that she had not asked him to come in, but that he had walked in anyway31. Ms Crisp also said that she knew nothing about Mr Harding-Roots having opened the door with a key. Ms Crisp said in the interview that she did not believe that an offence had been 30 Exhibit C95b, pages 2-3 31 Exhibit C95c, Answer 48

committed; the complainant was not alleging an assault, there was no property damage and there was no theft having regard to the fact that the keys were located in the letterbox. She did not believe that an offence of serious criminal trespass, nor unlawfully on premises, had occurred as Mr Harding-Roots had a lawful excuse to be there. Accordingly, there was nothing to report and a PIR was therefore not indicated.

Ms Crisp told the interviewing officer that the matter had been resolved by providing advice about what Ms Rankine could do to prevent Mr Harding-Roots from calling in the future. She said that Ms Rankine was happy to have her keys returned and there was no discussion about restraining orders or domestic violence orders. In addition, Ms Crisp did not believe that Ms Rankine was in any danger32. Furthermore she did not appear to be scared of Mr Harding-Roots33.

4.19. In her oral evidence before the Court, Ms Crisp said that Ms Rankine had not at any stage mentioned that Mr Harding-Roots had pushed his way into her unit34. She reiterated that Ms Rankine had said that Mr Harding-Roots had entered the unit by opening the door and coming in as if there was some form of implied consent that he could walk in and talk35. She said that Ms Rankine did not tell her that Mr HardingRoots had used the key to open the door36. She said that she had been talking to him through the screen door which was unlocked and that he had simply opened it and walked in37. In addition, Ms Crisp told the Court that Ms Rankine told her nothing about having seen Mr Harding-Roots drive past her property, or that when Mr Harding-Roots knocked at the door she had refused to answer. She mentioned nothing about any physical resistance to Mr Harding-Roots’ attempts to open the door38. Nothing was said about the force resulting in her falling backwards onto a lounge39. Ms Crisp also suggested that Mr Neailey had a quite limited involvement in the discussion that she had with Ms Rankine, suggesting that he may not have even been present for it.

4.20. Ms Crisp acknowledged that she had read the CAD report on the police vehicle’s computer screen prior to speaking to Ms Rankine. Accordingly, Ms Crisp would have to acknowledge that the allegations contained within that report were not consistent 32 Exhibit C95c, Answer 109 33 Exhibit C95c, Answer 110 34 Transcript, page 220 35 Transcript, page 226 36 Transcript, page 238 37 Transcript, page 238 38 Transcript, page 244 39 Transcript, page 245

with the account that Ms Rankine gave her. Ms Crisp acknowledged that she had received managerial support in respect of her performance in this incident. This had involved training in respect of the law in relation to the offence of trespass. She conceded that further action should have been taken by her in respect of the 18 June 2011 incident insofar as she believed that she should have gleaned more information in relation to the issue as to whether there had been permission to enter, and whether it had been express or implied.

4.21. In cross-examination Ms Crisp was specifically asked whether she had asked Ms Rankine about the information that had been included in the CAD report. She acknowledged that she was there to investigate allegations that a person had forced their way into the premises and that she had been knocked to the ground. When asked by Mr Griffin of counsel assisting whether she had asked Ms Rankine if Mr HardingRoots had pushed his way into her unit, she said: 'No, she explained it to me, I didn't need to ask.' 40 When asked as to whether at any stage she had asked Ms Rankine if she had been knocked to the ground Ms Crisp said ‘no’. When asked as to whether Mr HardingRoots had assaulted her, Ms Crisp said she did not ask that question; nor did she recall whether she asked Ms Rankine if he had ever assaulted her in the past. She acknowledged that she did not investigate the information that had been provided by Mr Neailey on the phone. Her explanation was that Mr Neailey had not been present during this exchange and was outside41. She did not ask Mr Neailey, for instance, what Ms Rankine had told him about the incident42. She acknowledged that there were differences in material aspects from the description of events contained in the CAD report and what Ms Rankine had described in person. Ms Crisp put it in these terms: 'Yes. I believe if she wanted to explain to us how the entry occurred and what happened to her, she would have told us and the reason she's explained it another way only she knows. But I'm assuming she maybe didn't want to get Harding-Roots into trouble, or glossed over it, or I can't really say.' 43 40 Transcript, page 229 41 Transcript, page 230 42 Transcript, page 231 43 Transcript, page 232

She also said that what is typed on the tasking is taken with a ‘grain of salt’44 and that emphasis is placed on what the person says when spoken to firsthand. By way of defence to a suggestion that her investigation lacked due rigour Ms Crisp said on a number of occasions in her evidence that her impression had been that Ms Rankine had simply wanted her keys back, and that she did not want to get Mr Harding-Roots into trouble45. To my mind taking what is contained in a CAD report with a grain of salt, and not exploring its content where differs from further information, is to be wilfully blind to the obvious and should never be tolerated as an aspect of police culture.

4.22. Ms Crisp also acknowledged that she did not speak to Mr Neailey about why he had reported the events in the terms that he had46.

4.23. It seems remarkable that on her own version of events Ms Crisp did not ask Ms Rankine why she was reporting Mr Harding-Roots’ behaviour in such an anodyne manner when the CAD report contained a complaint of a forceful trespass and assault.

Even on her version of events Mr Neailey, if not physically there when Ms Rankine was telling the police what had happened, was on the premises and he too could have been asked to explain why the complaint had been made in the terms that it had originally been made. There was no doubt that Mr Harding-Roots had at least removed, without permission, Ms Rankine’s keys from the premises and so the other sinister aspect of the original complaint, namely that the perpetrator had forcefully entered the premises and had applied unlawful physical force to the complainant, was therefore not intrinsically unlikely. Either Ms Rankine did in fact tell the officers exactly what had occurred, or if she did not, Ms Crisp appears to have turned a blind eye to the possibility that the perpetrator had committed offences significantly more serious than simply having entered against the occupier’s wishes, offences that would have to be reported and investigated.

4.24. Probationary Constable Schumacher also gave oral evidence. He had provided two statements dated 18 August 201147 and 18 May 201248. In the first statement Mr Schumacher asserts that Mr Neailey advised them that he had been the person who had contacted police regarding the incident. He asserts that Ms Rankine informed 44 Transcript, page 232 45 Transcript, page 233 46 Transcript, page 229 47 Exhibit C97 48 Exhibit C97a

him and Ms Crisp that she did not want Mr Harding-Roots inside the unit and so had spoken to him through the screen door. However, Harding-Roots had opened the door and walked into the unit regardless. Once inside the premises Ms Rankine had asked him for the spare key to the unit and to leave. He gave her the key but took another set of her keys. In the second statement Mr Schumacher asserts that Ms Rankine had made it clear to him that she did not want police to take any action in respect of any trespass that had occurred and that she only wanted her keys back. She had made it clear that she did not want to make a formal complaint in relation to an aggravated serious criminal trespass, and thus no PIR was raised. Neither statement deals with issues such as whether Mr Harding-Roots had entered the premises by use of the key, whether any force was used in entering the premises and whether Ms Rankine had been knocked over. The statements largely support Ms Crisp’s version of events, particularly in relation to what the two officers were told.

4.25. Mr Schumacher gave oral evidence and acknowledged that he would have known the contents of the CAD report. Asked in evidence as to whether Ms Rankine had told them how Mr Harding-Roots had actually gained entry to the premises, he said ‘aside from opening the door, I don’t remember’49. When asked as to whether she had said anything to the officers about whether he had used force to gain entry, Mr Schumacher said that he did not recall but that such an allegation would have been something that they would investigate further in relation to an assault. However, he had no notes of this and he did not remember whether Ms Rankine had said anything about force having been used. He did say that Ms Rankine did not appear as upset as he would have expected of someone who was alleging what originally had been communicated on the telephone50. In fact during his evidence Mr Schumacher repeated this observation on a number of occasions, as if to say that Ms Rankine’s demeanour somehow relieved the officers of an obligation to explore with her the allegations that had been encapsulated in the CAD report.

4.26. Mr Schumacher did agree with the suggestion that was put to him by me that between the two officers there had been a need to establish whether the information that had been imparted during the original phone communication was correct or not51. He agreed that there would have been a need to ask Ms Rankine whether she had been 49 Transcript, page 103 50 Transcript, page 103 51 Transcript, page 126

harassed by Mr Harding-Roots and whether he had pushed his way into her unit52.

Mr Schumacher said that he did not remember whether Ms Rankine was asked whether Mr Harding-Roots had pushed his way into the unit53. He said he could not recall resistance on her part being mentioned. Mr Schumacher did say that if Ms Rankine had said something that was contrary to the initial report, they would want to establish whether or not the original report was correct. He said that they would have questioned her further in relation to that issue and to have clarified what had actually occurred. Mr Schumacher asserted that he did not recall whether he or Ms Crisp had done so. Naturally if Mr Schumacher had recalled such an attempt at clarification it would have begged the further awkward question as to what Ms Rankine’s response had been. He was also not certain as to whether they had asked Ms Rankine if she had been knocked to the ground. He said: 'I believe we would have but I don’t recall asking that, no.' 54 When questioned further about that, and in particular whether their investigation had established whether Mr Harding-Roots had entered the apartment against the will of the complainant and had knocked her to the ground, he said: 'I don't recall that being something that was discussed at the time, no.' 55 When asked by me as to whether that was the very issue that they were there to investigate, Mr Schumacher agreed, and when further asked as to why he could not recall discussion about that if that was the issue they were investigating, he said: 'I don't know, I wasn't the lead investigator in this one and I don't recall the conversation had, unfortunately.' 56 Mr Schumacher agreed that if in his view his partner, Ms Crisp, had been inadequately investigating a particular matter he would have drawn his concerns to her attention, he said ‘immediately, yes’57. He acknowledged that he did not do so on this occasion.

4.27. There was one further matter of significance arising out of the attendance of officers Schumacher and Crisp at Ms Rankine’s premises following the 18 June 2011 incident.

52 Transcript, page 126 53 Transcript, page 127 54 Transcript, page 128 55 Transcript, page 128 56 Transcript, page 129 57 Transcript, page 129

I have referred to the fact that ultimately Mr Harding-Roots was spoken to on the telephone by Ms Crisp. It is apparent, and I so find, that all four persons were present when this telephone conversation took place. Ms Rankine told the Court in her oral evidence that in a telephone conversation that Ms Crisp had with Mr Harding-Roots, which she said she could hear on speaker phone, Mr Harding-Roots repeatedly said in response to questions by Ms Crisp as to where her keys were, that it did not matter if they arrested him because he was going to kill himself anyway58. After eventually revealing where the keys were, and after the phone conversation concluded, Ms Rankine asserted that Ms Crisp asked her ‘does he often say that?’, to which Ms Rankine replied ‘yes, all the time’59. Ms Rankine told the Court in effect that she, herself, did not take these threats seriously.

4.28. I observe that Ms Rankine’s first statement to police of 24 July 201160 mentions nothing about Mr Harding-Roots’ threat to kill himself, although she describes the call in which the location of the keys was revealed. The statement does set out the text of two SMS messages that she received from Mr Harding-Roots on 18 June 2011 and 20 June 2011 respectively in which he said that he was about to end it all as he could not go on anymore and in which he also said goodbye and made reference to some pills. She believed that he was talking about some tablets that she had left at his house at some point. However, in Ms Rankine’s witness statement of 21 May 201261 she asserts that on the final occasion that Mr Harding-Roots telephoned while the police were still present at the premises, the female police officer instructed her to answer the telephone and to put it on speaker. The statement asserts that after briefly speaking with Mr Harding-Roots the female police officer told him that if he came back to the unit he would be arrested and warned him not to come back, to which Mr Harding-Roots said to the female police officer ‘it doesn’t matter because I’m going to kill myself anyway’. The statement asserts that Ms Rankine told the female police officer that he said that all the time. I should add here that Ms Crisp and Mr Schumacher both denied that anything of the kind was said by Mr Harding-Roots and that, furthermore, the telephone was not on speaker to have enabled Ms Rankine to hear anything that Mr Harding-Roots had said.

58 Transcript, page 43 59 Transcript, page 44 60 Exhibit C4a 61 Exhibit C4d

4.29. Mr Neailey gave evidence about these telephone communications. He testified that he was present when a number of calls were received or initiated in respect of Mr Harding-Roots. He described one call where the male police officer telephoned and had asked whether the person who had answered it was Jeremy and he had heard a male voice on the phone reply ‘no’ and then hung up. Asked as to how he was able to hear that, Mr Neailey said that he was not sure whether it was on speaker phone or whether the volume had been loud enough for him to hear clearly.

4.30. He also gave evidence about a phone call that was received from Mr Harding-Roots that was initially answered by Ms Rankine. The phone was passed to the female police officer. Mr Neailey told the Court that he knew, by way of caller ID, that it was Mr Harding-Roots who had called. However, he told the Court that he believed that he could only hear the female police officer talking during the telephone conversation. During his evidence-in-chief the following passage of evidence was given by Mr Neailey in questioning by me: 'Q. Was there any other means by which you established that it was Jeremy HardingRoots who was on the other end of the line.

A. No.

Q. Did you hear his voice any stage, other than that initial conversation in which he'd apparently said, 'No.' A. No.

Q. So you didn't hear his voice again after that.

A. I don't believe I did.

Q. Were you made aware of anything that the person on the other end of the phone had said.

A. Actually I believe I heard him say, this is when the female officer asked for him to return the keys - Q. Yes.

A. - and I'm not 100% sure if he said where they were at that stage and then explained to him if you do this again we're going to have someone come arrest you. I believe he said, 'It doesn't matter I'm going to kill myself anyway.' Q. Who said that.

A. Jeremy.

Q. How did you know he said that.

A. I heard that.

Q. You heard that.

A. Yes.

Q. How did you hear that.

A. I'm not sure if it was just loud volume or - Q. Did anybody tell you that he'd said that.

A. No.

Q. You say you heard that for yourself.

A. I heard that with my ears.

Q. Did anyone say anything in response to that.

A. The police officer said, 'Okay, have a nice day', or something like that and hung up.

But she did afterwards ask Mandy does he tend to say that a lot and to which Mandy replied, 'Yes', and then she explained it's just an attention seeking behaviour.

Q. Who said that.

A. The female police officer.' 62

4.31. Although one of Mr Neailey’s witness statements63 briefly mentions the 18 June 2011 incident, it does not deal with the issue of telephone calls between police and Mr Harding-Roots.

4.32. In cross-examination Mr Neailey was challenged about his assertion that he had heard a statement by Mr Harding-Roots that he was going to kill himself. When asked as to why he did not at first volunteer having head Mr Harding-Roots’ voice, other than by way of saying ‘no’ as to whether it was Jeremy on the other end of the phone, he said that he had thought of it before but after giving his memory a ‘jog’64 he remembered.

Specifically, when it was put to him that he was mistaken about having heard these references to Mr Harding-Roots killing himself, he denied that he was mistaken, he said that he remembered it and was sure of it65. In reference to the suggestion that Ms Crisp had not made any comment about the issue. He said: 'No, she said that but then she asked Mandy does he normally say this type of stuff. She replied yes, then she said it's just an attention seeking behaviour.' 66 It was not directly put to Mr Neailey in cross-examination as to whether he and Ms Rankine had colluded in respect of their evidence in relation to this particular issue, but in response to questioning by Ms Shaw of counsel he said that he had not read any of her statements, nor had they been read out to him by her or that he had 62 Transcript, pages 428-429 63 Dated 24 July 2011, Exhibit C5a 64 Transcript, page 448 65 Transcript, page 458 66 Transcript, page 459

been told by her what was contained within them. I do not overlook, however, the fact that there is a strong resemblance between the manner and terms in which Mr Neailey described the assertion by Mr Harding-Roots that he was going to kill himself, and the manner in which the conversation is described in the statement of Ms Rankine of 21 May 201267.

4.33. As indicated earlier, both Ms Crisp and Mr Schumacher denied that Mr HardingRoots had made any threat to kill himself in any of the telephone communications that took place that day. Ms Crisp said that if she had been told by Mr Harding-Roots that he wanted to kill himself, she would have arranged the attendance of police at Mr Harding-Roots’ premises to investigate the matter and to make their own assessment68.

4.34. I have already referred to the documentation that was prepared following the 18 June 2011 incident and the police attendance at Ms Rankine’s premises. Ms Crisp was the only one of the two officers who made a handwritten note within a police notebook69.

Her note simply records that ‘Jeremy HARDING’ had attended Ms Rankine’s unit, had given a spare key back but had taken her set of keys. There is a further notation that she spoke to a person, a reference no doubt to Mr Harding-Roots, on ‘Mandy’s mobile’ and there is further reference to keys being located in the letterbox. There is nothing recorded about the circumstances in which Mr Harding-Roots gained entry to the premises. The note certainly does not record any conversation that allegedly occurred in which Ms Rankine stated that Mr Harding-Roots had entered forcefully and that she had been knocked over. The note makes no reference to the original information as contained on the CAD report. There is nothing recorded in relation to Ms Crisp’s phone conversation with Mr Harding-Roots except a reference to the letterbox. It contained nothing about a threat by Mr Harding-Roots to kill himself.

4.35. The CAD report entry that was uploaded the same evening contains a reference to police having spoken to a male person by phone from the address of the complainant, that the male person was advised to return (the keys) ‘asap’ to avoid action being taken and a further reference to the fact that the male person advised that the keys 67 Exhibit C4d 68 Transcript, page 222 69 Exhibit C95d

were in the letterbox and that the keys were located. There is further reference to the male ‘Jeremy HARDING’ being advised of the consequences of continuing to harass ‘Mandy’. Ms Crisp’s ancillary report, the circumstances and timing of the compilation of which I will deal with separately, is couched in these terms:

'POLICE ATTD RANKINE'S ADDRESS, STATED SHE HAD SPLIT UP WITH HER BOYFRIEND SOME MONTHS BEFORE AND HE HAD JUST ATTD HER ADDRESS. STATED ALTHOUGH HE HAD RETURNED THE SPARE HOUSE KEY ON LEAVING HE TOOK OFF WITH HER BUNCH OF HOUSE/CAR KEYS.

STATED SHE DID NOT WANT TO MAKE ANY REPORT, JUST WANTED HER KEYS BACK. SPOKE WITH JEREMY HARDING OVER THE TELEPHONE (041725) HE HAD ALREADY RETURNED TO HIS ADDRESS - HE STATED HE PUT THE KEYS IN THE LETTERBOX AND THEY WERE LOCATED IN THERE. ADVISED RANKINE TO STOP OPENING THE DOOR TO HIM AND TO CONTACT THE POLICE IF HE CONTINUED TO CALL OR ATTEND. ALSO ADVISED TO TRY BARRING HIS NO. FROM HER MOBILE PHONE.' 70 It is to be observed that the ancillary report contains some further information that was not contained in either Ms Crisp’s notebook entry or the CAD report, namely that Ms Rankine did not want to make any report and just wanted her keys back, and that Ms Rankine was advised ‘TO STOP OPENING THE DOOR TO HIM’, the implication being that Ms Rankine had opened the door to Mr Harding-Roots as opposed to Mr Harding-Roots having unlocked the screen door with a key and then forcing his way in against her will. I make the observation that this extra information could not have been included within the ancillary report on the basis of any note or other documentation that Ms Crisp had earlier raised in relation to the police attendance, including her notebook entry or the CAD report. It will be observed also that there is nothing in the ancillary report that refers to the original CAD report information that there had been a forced entry and an assault, nor is there any reference to there having been any investigation in relation to those allegations.

4.36. There is one further evidentiary matter that I should mention at this stage and it is that in Ms Rankine’s final written police statement dated 21 May 201271 it is recorded that she made the following assertion to police and thereafter signed the statement containing this assertion, namely: 'I was satisfied with the action that the Police took at the time and I didn't request the Police to take any further action against Jeremy. The Police didn't offer for anything 70 Exhibit C101 71 Exhibit C4d

more to be done at that time. However, had they offered to take further action against Jeremy at that time, such as arresting him for forcing his way into my unit, then I would have asked them to. I did not discuss any other options with the Police at that time. They had warned Jeremy not to continue to harass me and they had located and returned my keys to me. The two Police Officers did a good job at the time.' 72

4.37. In the event I was unable to make any finding on the balance of probabilities that Ms Rankine had informed Ms Crisp and Mr Schumacher that Mr Harding-Roots had forcefully entered the premises against Ms Rankine’s physical resistance and that she had been knocked over as a result. Any support that she derived about that issue from her partner, Mr Neailey, was insufficiently precise for a finding to be made. I was also concerned about the nature of Ms Rankine’s statement as reproduced in the preceding paragraph. There was a strong argument to suggest that Ms Rankine’s main objective in notifying the police on this occasion was not so much connected with any forceful entry to her unit by Mr Harding-Roots, but was more concerned with the retrieval of her keys, in particular her car keys which were needed for her work the following day. In addition, having regard to their previous relationship, I was also concerned that it was possible that Ms Rankine did not want to see Mr Harding-Roots in trouble with the police other than by way of what was necessary for the retrieval of her keys. That is not to say, however, that I have accepted the evidence of Ms Crisp and Mr Schumacher that nothing was said by Ms Rankine about Mr Harding-Roots’ use of the key to unlock the outside door and his forceful entry causing Ms Rankine to be knocked over. On the whole, I simply do not know where the truth lies in this regard. It seemed to me to be intrinsically unlikely that Ms Crisp would not have at least asked Ms Rankine to clarify the original information that was recorded on the CAD system that there had been such a forceful entry. On the other hand, as earlier indicated, it may well be that it suited Ms Crisp to be wilfully blind to that issue. If Ms Crisp had properly investigated the question as to how Mr HardingRoots had entered the premises and had made a proper notation either in her personal notebook, the CAD system or in an ancillary report, I could have had some confidence in accepting her evidence that Ms Rankine did not mention the forceful entry when she was describing what had happened in person. Clearly, in my view, there should have been some notation made by Ms Crisp about any inconsistency between what Ms Rankine told her verbally and what was contained within the original police communication.

72 Exhibit C4d, page 3

4.38. On the other hand, having regard to Mr Neailey’s evidence about the threat made by Mr Harding-Roots on the telephone to kill himself, supporting as it does Ms Rankine’s evidence about that issue, I am satisfied that Mr Harding-Roots did vocalise a threat to kill himself when speaking on the phone to Ms Crisp, and I am satisfied that there was a conversation between Ms Crisp and Ms Rankine about that to the effect that Mr Harding-Roots habitually made such threats in order to seek attention to himself. It may well be that Mr Neailey’s recall as to detail about what was said and what he heard is inaccurate. It may well be that he did not actually hear Mr Harding-Roots make the threat, but rather heard the conversation between Ms Crisp and Ms Rankine about that and had assumed since that time that he must have heard the actual threat made by Mr Harding-Roots. I closely observed Mr Neailey give evidence and I found nothing about his demeanour that would suggest that he was doing anything other than his level best to tell the truth as he remembered it to be. Mr Neailey was also not discredited in any way during crossexamination. The evidence of Ms Rankine and Mr Neailey that Mr Harding-Roots threatened to kill himself has a ring of truth to it, especially that aspect of the evidence in which Ms Rankine asserts that she downplayed the significance of such a threat. I do not accept the evidence of the two officers that Mr Harding-Roots did not make such a threat. Accordingly, I find that when Ms Crisp spoke to Mr Harding-Roots on the phone, Mr Harding-Roots threatened to take his own life. The impact of this threat may have been ameliorated in Ms Crisp’s mind by Ms Rankine’s assertion that Mr Harding-Roots was in the habit of saying such things. This might go some way to explain why police took no further action in respect of the threat, bearing in mind Crisp’s evidence that she would have arranged for a patrol to go out and see HardingRoots.

5. Mr Harding-Roots makes bogus enquiries about Ms Rankine - the 14 July incident

5.1. In July 2011 Ms Rankine was employed by Springmount Services as a cleaner. Her cleaning duties were carried out at Harbour Town situated on Tapleys Hill Road, West Beach. Ms Rankine’s partner, Mr Neailey, worked at Harbour Town as a security guard. As at 14 July 2011 Ms Rankine and Mr Neailey were temporarily residing at the West Beach Caravan Park due to work that was being undertaken at Ms Rankine’s Warradale unit. The West Beach Caravan Park is situated on Military Road at West Beach. As I understood the evidence, Ms Rankine’s unit had been

unoccupied for a period of time. It is not inconceivable that Mr Harding-Roots would have detected this from his own observations.

5.2. On the afternoon of 14 July 2011 two telephone calls were received by the marketing manager of Harbour Town, Ms Melanie Arthur. I will hereafter refer to this matter as the 14 July incident. It is clear that Mr Harding-Roots was the caller on both occasions. In both of these calls the same male caller claimed to be a police officer who was making enquiries about a cleaner by the name of Mandy, which undoubtedly was a reference to Ms Rankine. The calls were drawn to the attention of the operations manager of Harbour Town, Mr Michael Pentland. They were also drawn to the attention of Ms Rankine herself. Mr Neailey, who was a security officer at Harbour Town, was also made aware of the calls. In fact he was within the centre manager’s office when the second of the two calls was received.

5.3. There is some evidence to suggest that during the course of that day the receipt of these calls was reported to police, but there does not appear to be any written relevant SAPOL record. However, Ms Rankine herself would personally attend at the Sturt police station that evening and report the matter. An ancillary report was compiled in respect of her information. The report was tendered to this Court73. The only record of the incident that is known to exist within the management of Harbour Town was a note made by the operations manager, Mr Pentland, on the day74.

5.4. I will come to the details of these calls in a moment, but it should be stated at the outset that, notwithstanding the fact that police had an allegation that a male person, suspected to be Mr Harding-Roots, was making bogus enquiries about Ms Rankine, and also possibly in respect of her partner Mr Neailey, and was posing as a police officer in doing so, no police investigation or other intervention in relation to the matter ever ensued. Even after Mr Harding-Roots’ death later in July, the incident of 14 July 2011, an important part of the narrative leading to the incident on the day of Mr Harding-Roots’ death, was the subject of only the most perfunctory investigation.

For example, the fact that the caller was Mr Harding-Roots was only positively established during the currency of this Inquest through phone records. Statements were not taken from Ms Melanie Arthur or Mr Michael Pentland until September 2014 which was after the commencement of this Inquest. It is clear that in preparing her statement Ms Arthur was reliant on her unaided memory of these calls75.

73 Exhibit C98a 74 Part of Exhibit C107 75 Exhibit C115. Dated 18 September 2014

Mr Pentland’s memory only appears to have been refreshed to the extent of the briefly recorded information within his note of 14 July 2011.

5.5. Material was placed in the possession of police on 14 July 2011 by Ms Rankine that suggested that the caller in each of the calls had been Mr Harding-Roots, or at least raised the reasonable suspicion that he was the perpetrator. During the course of this Inquest evidence was provided to the Court that in my opinion establishes beyond all doubt that the caller was in fact Mr Harding-Roots.

5.6. Before dealing with the ancillary report that was raised by police as a result of Ms Rankine’s complaint of 14 July 2011 I should say something about the nature of the calls that were received at Harbour Town that day as they were understood by, and are within the recollections of, the persons who were involved in those telephone communications. Ms Rankine provided a brief account of what she had understood about the nature of the calls when she gave her very first witness statement to police on the day of Mr Harding-Roots’ death, namely 24 July 2011. Admittedly her understanding derives from hearsay, but it was she who would ultimately report the matter to police and she did so with a more than reasonable degree of accuracy. Her statement records that she was called into the office at her place of work at Harbour Town and was told that management had received a call from the police saying that police had stopped a car on Military Road and had found some chemicals with the name Springmount on them and drugs. Her understanding had been that the person claiming to be a police officer had said that these items had come from Ms Rankine.

The person asserting to be a police officer had asked for personal details concerning Ms Rankine, including whether she was working and what time she finished work.

Ms Rankine said in her statement that the officer had claimed that he was a Trevor Smith. Ms Rankine asserted a belief that Harbour Town management had telephoned Sturt police station as a result of the calls. Ms Rankine associated the caller with Mr Harding-Roots and in effect with an attempt on his part to stalk her. In her oral evidence before the Court Ms Rankine gave an account of what she had understood about these calls that augmented the account that she had given in her statement, including a reference to a belief that the caller had also enquired as to the name of her current boyfriend, who of course at that time was Mr Daniel Neailey. Ms Rankine testified that she also believed that the person claiming to be a police officer had said that he was from Southport police. Southport is on the Gold Coast in Queensland.

Ms Rankine told the Court that this strengthened the connection in her mind to Mr Harding-Roots because she and Mr Harding-Roots had together been on a holiday to the Gold Coast. I am not certain that the reference to Southport police as an aspect of her understanding of the calls is accurate. Regardless, I am satisfied that Ms Rankine had a rational suspicion that the caller had been Mr Harding-Roots. It also occurred to her that the reference to Military Road at West Beach was no coincidence because that was the location where she and Mr Neailey were currently residing. She thought that she may have been followed by Mr Harding-Roots.

5.7. Mr Neailey’s witness statement of 24 July 2011 makes very brief reference to this matter76. He was called into the centre manager’s office and was informed of the first call. In his statement Mr Neailey suggests that he was made aware that the person who had called was a Trevor Smith from the Drug Squad who had requested details about whether Mandy Rankine had a boyfriend, as he wanted to put them both under surveillance. He was told that there was a suspicion that the caller was Jeremy Harding-Roots pretending to be a police officer. Mr Neailey asserts in his statement that he was present for the second call which was put on speaker, but he does not provide any detail in the statement as to what was said or what he heard. In his oral evidence before the Court Mr Neailey confirmed the material in his statement. He elaborated upon what he understood had been said in the second call at which he was present. Mr Neailey told the Court that he believed that in the second call the caller gave a different name from Trevor Smith. On this occasion Mr Neailey thought that the man gave a name of Travis Smith, saying he was a CIB Detective currently in the Drug Squad, but soon to be going into the CIB. He heard the caller ask whether the Harbour Town management had the details of Ms Rankine’s boyfriend. Mr Neailey believed that Harbour Town management reported the incident to police.

5.8. The statements of Mr Pentland and Ms Arthur, taken as they were in September 2014more than three years after the event, do not provide as much detail as what Ms Rankine and Mr Neailey claim they understood from these calls. As indicated earlier, on the day in question Mr Pentland made a brief note. It recorded that Ms Arthur received a suspicious phone call regarding a Springmount employee, Mandy Rankine, and the caller was believed to possibly have been Ms Rankine’s ex-partner. The note recorded that this person phoned enquiring seeking personal 76 Exhibit C5a

details regarding Ms Rankine. The person claimed to be a police officer. The note records very briefly that a second call was received and the details had slightly changed. The note asserts that police were notified on both occasions. The note is not particularly helpful as to detail concerning what personal information about Ms Rankine had been sought. In any event Mr Pentland was not the person who spoke to the caller. His understanding of what was said was derived from Ms Arthur.

One matter that Mr Pentland does confirm in his statement is that the caller did give some details about himself, including a name, and that he appeared to be trying to locate Mandy Rankine.

5.9. Ms Arthur’s witness statement confirms that the caller was a male person who did provide a name, but she could not recall what it was. The person identified himself as a police officer and wanted to know if Harbour Town had a cleaner by the name of Mandy. Ms Arthur knew who the caller was referring to. Ms Arthur asserts that the caller said that police had stopped a car on Military Road with stolen goods inside and some of the items had Mandy’s name on them and that he needed to contact her.

Ms Arthur’s recollection was that the man said that he was a Sergeant and was from the Sturt police station. Ms Arthur states that the caller asked questions about Mandy, wanting to know personal details about her, but she could not remember exactly what he asked. Ms Arthur felt uneasy about all of this and asked if she could call him back at the Sturt police station so that she could verify his identity. He said that he would probably not be known at Sturt police station as he had just transferred from Queensland. It is this piece of information that conceivably gave rise to Ms Rankine’s mental association with Southport police. Ms Arthur states that Sturt police were called. Ms Arthur was advised by a person at Sturt police station that if Ms Rankine was concerned she should go to the police station and make a report. I pause here to observe that that is precisely what Ms Rankine did that evening.

Ms Arthur believes that the second call was initiated by her using a number that the caller had provided. Ms Arthur’s recollection is that the second call was quite short as the male person had detected scepticism on the part of Harbour Town staff and had hung up. I think that Ms Arthur is mistaken when she asserts a belief that she initiated the second call. Phone records would ultimately reveal that two calls were initiated from Mr Harding-Root’s landline. Ms Arthur states that Ms Rankine was informed about the matter and she stated that she believed it was an ex-boyfriend with whom

she had been having some trouble and that he was endeavouring to find out whether Ms Rankine still worked at Harbour Town.

5.10. To my mind what can be distilled from all of this evidence is that on 14 July 2011 there were two telephone conversations with the same man who claimed to be a police officer and who was making detailed enquiries about Ms Rankine, her whereabouts and when she would be off work, and also in respect to the identity of her boyfriend.

On both occasions the man asserted that he was a police officer making operational enquiries about material either suspected of being drugs or of having been stolen, all of which was found in Ms Rankine’s motor vehicle at a location on Military Road, West Beach.

5.11. It is plain, and I so find, that the telephone communications in question occurred on 14 July 2011. Mr Pentland’s note supports that finding as do telephone records that I will describe in due course. Equally clear is the fact that Ms Rankine that same evening presented at the Sturt police station counter and made a complaint in relation to the telephone communications. I find that Ms Rankine made the complaint on the same day that the telephone communications occurred. The complaint was taken by Senior Constable Jana Vallo. At that time Ms Vallo was on general station duties at the Sturt police station at Bedford Park. In her witness statement77 Ms Vallo confirms that at 9:38pm on 14 July 2011 she was approached at the counter by Ms Rankine.

Ms Vallo’s statement asserts that as of 23 September 2013, when the statement was given, she did not have any recollection of dealings with Ms Rankine. Her statement asserts that she does not recollect if Ms Rankine came to the station with any other person. There are other matters that Ms Vallo asserts she does not recall. I will mention some of those in due course. Ms Vallo confirms that she submitted an ancillary report78. The report is timed at 2138 hours on 14 July 2011.

5.12. The ancillary report contains information that has obviously been imparted to Ms Vallo on this occasion. The salient features of the information recorded in the ancillary report are: that the ‘subject’, undoubtedly a reference to Mr Jeremy Harding-Roots of his  address at Para Hills West, and the complainant, Ms Rankine, had ended their relationship in April 2011; 77 Exhibit C98 78 Exhibit C98a

that Ms Rankine received information from a colleague that a male person had  phoned her operations centre; the male person had stated to the recipient of the call that he was a police officer  named Trevor Smith from Sturt police station; the caller had asserted that he had pulled over a car on Military Road and found  drugs and Springmount cleaning products in the car, Springmount being the complainant’s employer. The caller had asked the occupants of the car where these items had come from. The occupants had allegedly provided Ms Rankine’s name; the police officer/caller had asked the recipient of the call if Ms Rankine was  working because he wanted to find her boyfriend’s name who was allegedly one of the persons whom he had pulled over in the car on Military Road; the recipient of the call had stated that Ms Rankine was working and had also  provided the police officer/caller with her working hours at Harbour Town; the ancillary report also records that Ms Vallo was told that the recipient of the  call wished to call the police officer/caller back, but that he stated that she could not telephone him; the recipient phoned Sturt police station and enquired whether Trevor Smith was a  police officer at Sturt which was ‘declined’; that the police officer/caller phoned again and the same recipient answered the  call. The person repeated himself and asked the recipient the name of Ms Rankine’s boyfriend which was not provided; the recipient of the calls spoke to Ms Rankine and informed her of the matters  recorded.

The ancillary report does not record any particular concerns on the part of Ms Rankine such as whether she was apprehensive of the person who had called, be it Mr Harding-Roots or otherwise. The clear inference from the contents of the police ancillary report looked at as a whole is that Ms Rankine was reporting her belief that the caller was in fact Jeremy Harding-Roots and that he was making bogus enquiries about her and her partner in a bogus capacity as a police officer investigating possible criminal offences in which Ms Rankine and her partner were possibly implicated.

5.13. The ancillary report was loaded directly onto PIMS by Ms Vallo that evening.

5.14. Section 74 of the Police Act 1998 renders it an offence for a person without lawful excuse to represent himself to be a police officer by word or conduct. A person so representing himself when in fact that person was not a police officer would generally have no lawful excuse to do so and therefore would be guilty of this offence. The maximum penalty for a contravention of this provision is a fine of $2,500 or imprisonment for 6 months. A police officer for these purposes is defined as a member of SA Police or of any other police service or force in Australia. Essentially, the complaint that was received by Ms Vallo from Ms Rankine was that her former partner, Mr Jeremy Harding-Roots, had approached her employer falsely representing himself as a police officer in order to ascertain personal details about her, including whether she was working at Harbour Town and also as to the name of her current boyfriend. The complaint also carried an implication that Mr Harding-Roots was possibly also driven by a desire to sully the character of Ms Rankine and her current boyfriend by alleging that drugs and suspected stolen cleaning products had been found in their possession. The facts of this complaint as recorded by Ms Vallo disclosed the suspicion of a serious criminal offence, namely impersonating police contrary to section 74 of the Police Act 1998. The complaint also identified a suspect.

A natural enquiry on the part of any police officer receiving such a report would be to ask the complainant what it was that she wanted done about it. However, regardless of the complainant’s attitude, such an allegation would require investigation in the public interest.

5.15. The other matter that also may have enlivened a healthy curiosity on the part of police would be knowledge of the 18 June 2011 incident, also having involved Mr HardingRoots. If it was understood by police that on that occasion Mr Harding-Roots had forcefully entered Ms Rankine’s premises causing her to be knocked over, coupled with assertions on his part, that evening and on other occasions, of an intent to kill himself, the need for police action as of 14 July 2011 would have been all the more acute. In any event, regardless of the earlier incident in June 2011, there was a requirement on the part of Ms Vallo to have treated this complaint as the report of a criminal offence and to have taken the necessary and appropriate action including the compiling of a police incident report.

5.16. The police ancillary report that was taken in relation to Ms Rankine’s complaint about the incident of 14 July 2011 does not contain reference to anything that Ms Rankine may have wanted police to do in respect of her complaint. It would seem to be inherently unlikely that Ms Rankine would go to the trouble of making such a complaint without having an objective. Equally as unlikely would be a scenario in which Ms Rankine did not verbalise to police something that was on her mind as far as her objective was concerned. I think it is also unlikely, regardless of what Ms Rankine had told police in respect of the 18 June 2011 incident, that if again questioned about that incident she would have described Mr Harding-Roots’ behaviour in the benign terms that Ms Crisp and Mr Schumacher allege she did.

5.17. Ms Rankine’s first statement to police of 24 July 2011 does not say anything about what Ms Rankine’s objective had been when she made the report of 14 July 2011, nor what she may have asked the police to do in respect of her report. Her subsequent statements say nothing of that either.

5.18. Mr Neailey’s statements are silent firstly as to what he understood Ms Rankine’s objective had been in reporting the 14 July incident, and secondly whether he had any understanding as to what if anything Ms Rankine may have asked the police to do.

5.19. Ms Rankine gave oral evidence about this matter. She told the Court that she attended at the Sturt police station on the same day as the incident. Ms Rankine told the Court that she believed that she went there with her then friend and supervisor at work, Ms Debbie Smith79. In her own evidence Ms Debbie Smith confirmed that she attended at the Sturt police station with Ms Rankine when the complaint about the Harbour Town incident was made. In Ms Smith’s original witness statement dated 6 October 201180 she indicated that she had first become aware of the Harbour Town incident when she was in Whyalla. Ms Rankine contacted her by telephone about that matter. In her oral evidence before the Court Ms Smith said that she had been in Whyalla for only a few days. She did not have any record of the dates that she had been in Whyalla. She said that it was after she returned from Whyalla that she attended at the Sturt police station with Ms Rankine. However, it is clear that the incident involving phone calls to Harbour Town and in respect of Ms Rankine’s attendance at the Sturt police station all occurred on the one day, that is 14 July 2011. To my mind Ms Smith was 79 Transcript, pages 69, 72 80 Exhibit C19a

mistaken when she asserted a belief that she was in Whyalla when she first heard of the incident. Ms Smith told the Court that she knew of the history between Ms Rankine and Mr Harding-Roots and that she was aware that Ms Rankine wanted Mr Harding-Roots to leave her alone and that she did not want to have anything to do with him81. She had given Ms Rankine advice that Ms Rankine should obtain a restraining order. She believed that Ms Rankine wanted to do this. In fact, Ms Smith told the Court that it was her own idea to go to the Sturt police station82. She formed this idea because, to use her words, ‘I was worried for Mandy’s safety’83. Her expectation was that the police would go and talk to Mr Harding-Roots and give him a warning not to go near Ms Rankine again. As well, she thought that Ms Rankine could obtain a restraining order against him. Having observed Ms Smith give oral evidence I was perfectly satisfied that she told the Court the truth when she said that she accompanied Ms Rankine to the Sturt police station when Ms Rankine reported the incident of that day.

5.20. Ms Rankine gave oral evidence that when she reported the matter at the Sturt police station she was the person who did much of the talking and was not asked questions such as those relating to her relationship with Mr Harding-Roots, whether she was concerned about his behaviour and whether there was any history of domestic violence between them. She said that the person did not ask her a lot. Ms Rankine told the Court that she related to the person taking the report all she knew from the incident of that day and also that Mr Harding-Roots had been sending her text messages and telephoning her all the time. She said that she asked about a restraining order and was told by the person that there was nothing they could do84. She also said that she was not asked whether she wanted to press any criminal charges in respect of Mr Harding-Roots’ behaviour85.

5.21. In her evidence Ms Smith told the Court that at the Sturt police station Ms Rankine asked the person to whom the report was made as to whether she could obtain a restraining order against Mr Harding-Roots, to which the response was negative on the basis that Mr Harding-Roots would have to physically harm Ms Rankine before a restraining order could be entertained. Ms Smith put it in these terms: 81 Transcript, page 287 82 Transcript, page 292 83 Transcript, page 292 84 Transcript, page 69 85 Transcript, page 71

'… they said 'No', basically he had to go and physically harm her or go up to her or do something to her for them to actually give a restraining order, which I commented I thought that was quite silly because what - does it leave it 'til the end? You know, and something actually happens to Mandy before the law will actually help her.' 86 Naturally, any such advice would have been nonsense.

5.22. Senior Constable Jana Vallo was the police officer who took the report relating to the 14 July incident. Ms Vallo gave oral evidence on two occasions. Her recall was necessitated by a revelation that emerged during the course of Ms Crisp’s oral evidence. I will come to that in a moment. Ms Vallo signed a witness statement on 23 September 2013. She did so at the request of Detective Sergeant Adam Serafini of the Internal Investigation Section. In that statement she said that she did not have any recollection of dealings with Mandy Rankine. However, in her oral evidence Ms Vallo gave some vague evidence about having connected the incident in which Mr Harding-Roots lost his life, which she heard about on the day of that event, with the report that she had taken in relation to Mr Harding-Roots in July 2011. She had remembered his name87. In any event Ms Vallo said in her evidence that she had no recollection of taking the report when she was spoken to by Detective Sergeant Serafini in 2013 and also, in any case, it appears that even if Ms Vallo had made a mental connection between the events surrounding Mr Harding-Roots’ death with the report that she had taken about him earlier that month, she did not draw any such connection to the attention of the police who were investigating the circumstances of Mr Harding-Roots’ death.

5.23. In her oral evidence before the Court Ms Vallo acknowledged that she had correctly understood her responsibilities in relation to whether or not a report of an incident should attract a police incident report as opposed to a police ancillary report. The criterion involved was whether the report disclosed the commission of an offence88.

She told the Court that at the time with which this Inquest is concerned she was aware of the criminal offence of stalking. She was also aware of the availability of restraining orders or the like at that time. She told the Court that her practice in taking a report was to ask questions and to try to establish whether an offence had been committed in a particular case. In this case she determined that the report did not establish the commission of any offence and so she thought it appropriate to submit an 86 Transcript, page 293 87 Transcript, pages 144-145 88 Transcript, page 154

ancillary report. As seen earlier, this determination was erroneous. Ms Vallo explained that there were two methods by which an ancillary report could be entered onto the SAPOL system, one being to type it straight onto the system, the other being to prepare a written report in the first instance. A written report is known as a PD345.

Either way she would submit the report before the end of the shift. I infer from the fact that Ms Vallo entered the report straight onto the system that there was no further vetting of her report, and in particular no or no proper analysis by any other police officer as to whether or not the ancillary report was the appropriate method of posting the report. If the report had been submitted as a hard copy PD345 she would have expected the document to be vetted by a supervisor and then be transferred to the Crime Management Unit89. The evidence is unclear as to whether this report ever saw the light of day within the Crime Management Unit. Any proper vetting would immediately have identified the complaint as one that involved an allegation of a serious criminal offence committed in the context of an ongoing acrimonious relationship breakdown and that it required the compilation of a police incident report.

5.24. During the course of her evidence that was given on the first occasion, Ms Vallo came to acknowledge that the report taken on this particular occasion amounted to a complaint that Mr Harding-Roots had been impersonating a police officer in an attempt to gain personal information about the complainant and her boyfriend90. Ms Vallo acknowledged that in 2011 she had been aware of the existence of the offence of impersonation of a police officer, but that she did not understand the penalties for that offence91. She told the Court that at the time it did not occur to her that part of Ms Rankine’s complaint involved an allegation that a person had misrepresented himself by word in a telephone conversation to be a police officer92. Ms Vallo told the Court that if it had occurred to her that the report amounted to a complaint of an offence under section 74 of the Police Act, she would have submitted a PIR93. While I accept all that evidence as truthful, I do not accept that it was reasonable for Ms Vallo to have overlooked the offence of impersonating police. It is evident to the Court that Ms Vallo wholly failed to consider the implications of the nature of Ms Rankine’s report. For instance, it does not appear to have occurred to Ms Vallo that the information that Ms Rankine was imparting was hearsay that might be required to be 89 Transcript, page 168 90 Transcript, page 175 91 Transcript, page 184 92 Transcript, page 185 93 Transcript, page 185

established from the original source of the information. It will be noted that in the report the provider of first hand information is described as the ‘recipient’ of the calls.

Ms Vallo acknowledged that the investigation of a criminal offence would require first hand information from the ‘recipient’ and would require the identification of that person. It also did not occur to Ms Vallo that it would be necessary to establish whether a police officer by the name of Trevor Smith existed or not, and if he did exist whether that person had made the calls in question94. Ms Vallo’s imperfect lack of understanding of her function at the time she took the report is exemplified by an assertion that police do not establish the name of an informant, in this case the first hand source of the information about the calls, ie the recipient. Asked to explain why that would be so if the identity of the original informant could be established, she said ‘because the names of complainants should be suppressed – or informants’95. This of course is complete nonsense. Ms Vallo no doubt had in mind here the undesirability of police informants’ identities being revealed and the privilege that exists in relation to the disclosure of such identities, but having regard to the nature of the complaint being made by Ms Rankine in this particular case, it would be absurd to suggest that Ms Rankine should not have been asked to disclose the identity of the person who had received the calls in the first instance, either by name or by job description. Even if the matter was to be properly recorded on an ancillary report for the purposes of police intelligence only, in a case such as this there could not be any sensible objection to the name or job description of the recipient of the calls being enquired of and recorded. And naturally the need to establish the identity of the recipient of the calls would be absolutely crucial if Ms Vallo had concluded that the report involved the alleged commission of an offence by an identified suspect. Asked as to why she did not ask Ms Rankine for the name of the recipient of the calls she said: 'Because at the time I thought it wasn't appropriate to ask that question, I can't answer it otherwise.' 96

5.25. Ms Vallo agreed with counsel assisting, Mr Griffin, that if she had compiled a PIR one of the matters that she might have recorded in the investigation diary was a need for a person to attend and obtain a statement from the recipient of the call97. Such an investigation might also involve the obtaining of telephone records to establish 94 Transcript, pages 179-182 95 Transcript, page 176 96 Transcript, page 176 97 Transcript, page 188

whether there was any substance to the allegations. She agreed that by submitting an ancillary report only, no such investigation would be triggered98. She also accepted that the need to investigate an allegation of impersonating a police officer, if a PIR had been filed, would not have been dependent upon the complainant’s willingness to press charges in respect of the matter because the complainant would not be the victim of the offence herself. She agreed that in the case of impersonating a police officer, the complainant would not be a victim. In this respect in my view is that Ms Vallo is correct. The investigation of an offence of impersonating a police officer is quite clearly one to be conducted in the public interest regardless of the attitude of the person bringing the matter to the attention of police.

5.26. Ms Vallo also agreed with counsel assisting that the history of the relationship between the complainant and the suspect was a matter that would require due enquiry, and in particular whether Mr Harding-Roots in the past had used a phone to make harassing or menacing calls. She acknowledged that it is something that she should have enquired about99. The same applies in relation to any history of previous incidents. In fact, in this regard, on the first occasion she gave oral evidence Ms Vallo told the Court that at no stage had she been made aware of the allegations underlying the 18 June incident at Ms Rankine’s unit at Warradale. She was not aware of any allegation that Mr Harding-Roots had forcibly entered Ms Rankine’s unit and had taken a set of keys100. However, although she had subsequently been made aware of an ancillary report that had ultimately been filed by Ms Crisp, she had no access to that report on 14 July 2011 when she took her own report. She told the Court that if she had access to that report as of 14 July 2011 she would have done things differently, namely she would have asked questions in relation to phone calls that had been made and about the history between the two people. She said that if she had been aware that police had in effect warned Mr Harding-Roots to stay away from Ms Rankine and that they would possibly arrest him if he did not, this was a matter that she herself would have needed to take into account because it would then have been appropriate to ask Ms Rankine questions in connection with the possible offence of stalking. This may have prompted her to submit a PIR and to obtain a statement from Ms Rankine101.

98 Transcript, page 189 99 Transcript, page 190 100 Transcript, page 199 101 Transcript, page 200

5.27. As to the question of a restraining order, Ms Vallo told the Court that she did not remember a request for such an order. She did not believe that on the information contained within her ancillary report there would have been sufficient information to consider a restraining order102. However, if a restraining order had been enquired about she acknowledged that she would have asked questions in relation to the history of the relationship between the complainant and the suspect to see if that would provide grounds for a restraining order to be considered103. It is evident that Ms Vallo did not explore the relationship in any significant detail. I have found that when Ms Rankine attended Sturt police station and made her report on the 14 July incident, a restraining order or the like was requested. I have accepted Ms Rankine’s evidence, supported as it is by that of Ms Smith whose evidence I accept, that an order was sought.

5.28. Ms Vallo told the Court that it was general practice to print off a copy of the uploaded ancillary report and to place it in a basket in the station office. There is no evidence that any other person looked at any such copy or vetted it, let alone raised with Ms Vallo any obvious shortcoming in respect of it.

5.29. Ms Vallo’s evidence that she did not see Ms Crisp’s ancillary report and of what she would have done if she had seen it, must be looked at in the light of Ms Crisp’s evidence before the Court. Ms Crisp gave evidence after Ms Vallo had given evidence. Ms Crisp told the Court that on about 15 July she and Ms Vallo had discussed the Rankine matter and that Ms Vallo had asked to see Ms Crisp’s ancillary report in respect of the 18 June incident. Ms Crisp said in her evidence-in-chief, as elicited by her counsel Ms Shaw, that she did not have any specific memory as to when it was in relation to the 18 June incident that she had actually typed up her ancillary report, but said that she normally typed it ‘in the next couple of days after the incident’104. Ms Crisp identified Exhibit C99 as the ancillary report that she believed would have been typed up by the Crime Management Unit on the date that it bore, namely 15/7/2011 at 0800 hours. This date of course is the date following the 14 July 2011 incident that was reported to Ms Vallo. This is a PIMS generated document, not a hard copy PD345 that would have been typed by Ms Crisp herself.

Asked by me as to when it actually was that Ms Crisp had composed the narrative that 102 Transcript, page 197 103 Transcript, page 196 104 Transcript, page 224

is contained in the ancillary report, Ms Crisp said that she normally did this within days of attending the incident; sometimes on the same day depending on whether she had the time. She acknowledged, on the other hand, that a PIR would have to be submitted during the same shift. She knew of no similar requirement in respect of an ancillary report105. The document that Ms Crisp compiled was not the document that was eventually entered onto PIMS. Ms Crisp told the Court at this point in her evidence that she did not know what would have happened to the hard copy. She told the Court that the hard copy would go to Intel, that she would have no control over when it was uploaded to PIMS and that sometimes it could take months106. Ms Crisp was asked this question in cross-examination by counsel assisting, Mr Griffin: 'Q. Are you quite confident that you drafted the hard copy of the ancillary report within days of the actual attendance at Warradale.

A. Yes.' 107 I say here that further evidence would be given that brings that answer into question.

I will mention that presently. That Ms Crisp in giving that answer was not misled by the terms of the question is supported by the fact that she had emphatically rejected the suggestion put to her by counsel assisting that she only drafted an ancillary report for the first time when Ms Vallo had asked her for it108. Although no objection was taken to this question at the time it was asked, counsel for Ms Crisp later complained that it misrepresented what Ms Crisp had earlier said as to when it may have been that she compiled the draft hard copy. Notwithstanding this, to my mind there was nothing unfair about the question, put as it was to an experienced police officer who, to a certain extent, had committed herself twice to the suggestion that the ancillary report probably would have been drafted by her within a few days of the 18 June 2011 incident. Ms Crisp was quite at liberty to have refuted counsel’s suggestion that she was ‘quite confident’ about that. I took the whole of her evidence to that point to be that due to her usual practice she was confident that this ancillary report would have been drafted within days of the actual incident at Warradale. In the event, as will be seen, Ms Crisp’s confidence in that regard was severely dented, and that the draft was probably not prepared until on or about 15 July 2011, the day after the 14 July incident.

105 Transcript, page 254 106 Transcript, page 256 107 Transcript, page 258 108 Transcript, page 258

5.30. It was during Ms Crisp’s cross-examination by Mr Griffin that Ms Crisp for the first time revealed that she remembered Ms Vallo coming to her and saying that she had seen Mandy Rankine in the police station and that she, that is Ms Vallo, had tried to locate Ms Crisp’s ancillary report in respect of the 18 June incident. As a result of this approach, Ms Crisp discovered that contrary to her expectation her ancillary report had not been uploaded onto the system. She said that although she could not remember exactly what had happened, she found the report and put it on top of a pile in the expectation that it would then be put onto the system. She did not recall the day on which this had all occurred. If this was correct it would mean that Ms Vallo’s evidence that she had not known about any previous incident involving Ms Rankine was not correct. At the time Ms Crisp gave evidence on this topic the Court did not have access to any draft hard copy PD345 ancillary report that Ms Crisp may have created.

5.31. Ms Crisp told the Court that she read Ms Vallo’s ancillary report about the 14 July incident which she said did not make much sense to her. She believed that there was an actual officer at Sturt police station with the name mentioned in the report. She did not appreciate that the complaint amounted to an allegation that Mr Harding-Roots had rung Ms Rankine’s workplace and had pretended to be somebody else, that is a police officer. She did not believe that Ms Vallo had explained to her that the incident that had been reported to her involved the impersonation of a police officer109.

She at no stage thought that the complaint underlying Ms Vallo’s ancillary report could have involved Mr Harding-Roots endeavouring to contact Ms Rankine at Harbour Town. It must be said, however, that if she had had any meaningful conversation with Ms Vallo about the matter, it would have been readily revealed to her that Mr Harding-Roots’ alleged behaviour was the subject of Ms Vallo’s ancillary report.

5.32. Asked to clarify the purpose of Ms Vallo having approached her and what, if anything, she was trying to convey to Ms Crisp, Ms Crisp said that she wanted to find a report about ‘a job at her unit’ (meaning Ms Rankine’s Warradale unit) and that Ms Vallo must have seen something that indicated that Ms Crisp had had an involvement in that job110. Ms Crisp’s response was that there should already be an ancillary report in relation to it, to which Ms Vallo said that there was not one and that this had then 109 Transcript, page 261 110 Transcript, pages 261-262

prompted her to take the necessary steps for it to be put on the system. Asked as to how Ms Vallo would have known to approach Ms Crisp about the matter, Ms Crisp suggested that this may have been obtained from the CAD system111.

5.33. Although Ms Crisp had earlier said in her evidence that it did not occur to her that the complaint to Ms Vallo may have involved Mr Harding-Roots trying to get in contact with Ms Rankine in Harbour Town, she did say that as Ms Rankine had made the complaint, she had assumed that it had something to do with Mr Harding-Roots. She assumed that she would have informed Ms Vallo of what her own involvement had been with Ms Rankine112. Ms Crisp also assumed that she would have told Ms Vallo what had taken place in respect of the incident at Ms Rankine’s premises and of the version of events that Ms Rankine had given her at that time113. She assumed that Ms Vallo would know that they were talking about the same person, namely Jeremy Harding-Roots114. However, Ms Crisp said that if she and Ms Vallo had concluded that Mr Harding-Roots had been involved in two separate incidents involving Ms Rankine she said: 'I would have seen that he's done something else, but whether there was any need for - whether there was an offence committed, I mean that was up to Vallo, or further investigation. But for my part I wasn't going to begin an investigation into what had happened after she made that report.' 115

5.34. Ms Vallo was recalled to deal with Ms Crisp’s evidence that she had consulted Ms Crisp about the matter. Ms Vallo stated that she did not remember this116. She told the Court that she knew Ms Crisp in 2011, but that she had no recall of any conversation with Ms Crisp after entering her ancillary report of the 14 July incident.

She acknowledged that it was possible, that she had such a conversation but that she did not remember it. When she was asked to examine Exhibit C99 which was the uploaded ancillary report of Ms Crisp relating to the 18 June incident, she had no recollection of that information having been reported to her at the time117. She said that she had no recollection of using CAD records or other means of identifying an involvement of Ms Crisp in relation to Ms Rankine, or of speaking to her to chase up 111 Transcript, page 262 112 Transcript, page 264 113 Transcript, page 264 114 Transcript, page 264 115 Transcript, page 265 116 Transcript, page 463 117 Transcript, page 466

where her paperwork was118, although she acknowledged that it was possible that she had been made aware by Ms Rankine that there had been a previous incident involving Mr Harding-Roots119. She also acknowledged the possibility that she had spoken to Ms Crisp and had actually informed her of the nature of the complaint that Ms Rankine had made to her in respect to the Harbour Town incident120.

5.35. Asked as to what course of action Ms Vallo may have taken if Ms Crisp had told her about her earlier involvement with Mr Harding-Roots and Ms Rankine, Ms Vallo said that she would have made further enquiries with the reporting person, Ms Rankine, to ascertain whether there were any further incidents of relevance. She may have used any such further information to make further enquiries and possibly to submit another report and to then pass the matter on to her supervisor. She said that she would have asked more questions in relation to what had taken place recently between Ms Rankine and Mr Harding-Roots and in particular about phone calls, their frequency and their content121.

5.36. During the course of the Inquest counsel for the Commissioner of Police and Senior Constable Crisp, Ms DePalma, produced to the Court a hard copy draft of Ms Crisp’s ancillary report, the PD345. It will be remembered that Ms Crisp gave evidence that at some point she had prepared such a document which she would have expected to have been uploaded to PIMS. It was established in evidence that although the PIMS version of the ancillary report was said on the face of the document to have been entered on 15 July 2011 at 0800 hours122, it was in fact not uploaded until 16 August 2011 at 1326 hours by administrative officer, Ms Samantha Slattery. Ms Slattery told the Court that the date of 15 July 2011 at 0800 hours is explained by the date that had been typed on the original draft, namely 15/7/11, and that the 0800 hours was entered for the sake of convenience. All this means that Ms Crisp’s ancillary report of the 18 June incident was not uploaded to PIMS until three weeks after Mr Harding-Roots’ death.

5.37. The hard copy of Ms Crisp’s PD345 ancillary report retrieved from SAPOL records has a box for the ID number of the officer who has vetted the report. There is no entry in respect of this report. There is no evidence that any person vetted the 118 Transcript, page 469 119 Transcript, page 470 120 Transcript, page 470 121 Transcript, page 475 122 Exhibit C101

document subsequent to its completion. The likelihood in my view is that neither the ancillary report relating to the 18 June 2011 incident nor that relating to the 14 July 2011 incident were ever properly vetted. However, there is a stamp on the hard copy PD345 ancillary report of Ms Crisp suggesting that it was approved by Sturt Intel.

What that approval consisted of is not clear, but whatever it did consist of it did not result in the report being uploaded to PIMS in a timely manner.

5.38. The fact that Ms Crisp’s ancillary report was not uploaded for another month after its compilation was explained as being probably due to a routine backlog.

5.39. No hard copy ancillary report other than the PD345 dated 15/7/11 (Exhibit C101) was produced to the Court. I have accepted Ms Crisp’s evidence that she was approached by Ms Vallo at a time after Ms Vallo had taken the report from Ms Rankine on 14 July 2011 and that Vallo asked her for her ancillary report relating to the 18 June 2011 incident. The fact that a PD345 ancillary report came into being on 15 July 2011 which was the day after the 14 July incident is in keeping with an approach by Ms Vallo to Ms Crisp for her report. It seems clear enough that as a result of that approach Ms Crisp created the PD345 ancillary report on 15 July 2011. When Ms Crisp gave evidence in this Inquest on the first occasion, her PD345 (Exhibit C101) had yet to be made available to the Court and so it was that Ms Crisp was not asked to explain the existence of a hard copy PD345 ancillary report with that date on it. It will be remembered that Ms Crisp’s evidence was that she would have compiled her hard copy ancillary report within days of the incident, not nearly a month after the incident and only when pressed by another police officer who was also involved in the Rankine / Harding-Roots matter to do so.

5.40. When Ms Crisp was recalled she was asked to explain the origin of the hard copy PD345 ancillary report dated 15/7/11. There had been a further revelation during the course of the Inquest that at 9:04am on 15 July 2011 Ms Crisp had electronically accessed Ms Vallo’s ancillary report that was already uploaded on PIMS. Ms Crisp accepted that she performed that exercise. She reiterated that she had also spoken to Ms Vallo. She believes that she must have received an email from Ms Vallo in which the ancillary number was provided to her. There was no email record, but I accept that there must have been some written and/or verbal communication between the two of them to have enabled Ms Crisp to access Ms Vallo’s ancillary report. What Ms Crisp told the Court was that she believed she had not been able to locate her original

draft ancillary report and that she therefore, on 15 July 2011, ‘retyped it’123. Ms Crisp, in accordance with her usual practice, was still of the belief that she had drafted an ancillary report within days of the 18 June 2011 incident but that, for whatever reason, it had not been uploaded onto the system by the time Ms Vallo came to take Ms Rankine’s report on 14 July 2011. It is true that in the early house of the morning of 19 June 2011, as part of the same shift in which Ms Crisp had attended at Ms Rankine’s premises at Warradale, she had made a note on the Offender Record Management System (ORMS) that she intended to file an ancillary report in relation to the matter. However, this notation would not have served to remind Ms Crisp to do that and the question is therefore begged as to why she would not have compiled the ancillary report in draft form at least during the course of that shift. In any event it is obvious that no such ancillary report was ever uploaded onto PIMS until after Ms Crisp on 15 July 2011 created the hard copy which was ultimately placed onto the system by Ms Slattery on 16 August 2011. Ms Crisp did acknowledge the possibility that she had forgotten to create a draft ancillary report soon after 18 June 2011124, but her preferred position was that she had created such a document at an early point in time and that for whatever reason it had been misplaced and not uploaded onto the system. This prompted counsel assisting, Mr Griffin, to suggest that Ms Crisp’s evidence amounted to an excuse akin to the dog having eaten her homework. Counsel for Ms Crisp rejected this characterisation.

5.41. The issue as to when Ms Crisp first created her ancillary report is of importance. Ms Crisp stated that the hard copy PD345 ancillary, Exhibit C101, would have been compiled from memory in conjunction with her original notebook entry. However, I observe that her original note would not have assisted to any great extent other than in relation to formalities. If Ms Crisp had compiled an ancillary report for the first time on 15 July 2011 from what amounted to unaided memory, it was in my view an exercise fraught with probable imprecision.

5.42. I do not know where the truth lies in relation to when for the first time a report was created in relation to the 18 June 2011 incident. I am not prepared to accept vague assertions on Ms Crisp’s part that in the normal course of her work she would have created a report within a few days of the 18 June 2011 incident. In any event the fact that a report such as that was not uploaded onto the system for two months is a most 123 Transcript, page 663 124 Transcript, page 680

unsatisfactory state of affairs. Clearly there should have been a marrying of a report in relation to the 18 June 2011 incident with a report in relation to the 14 July 2011 incident so that a thorough and necessary police investigation into Mr Harding-Roots’ activities could have been undertaken. It may well be that if there had been any reluctance on Ms Rankine’s part to properly describe Mr Harding-Roots’ behaviour on 18 June 2011, and to water down what he actually had done, her reluctance in the light of the events of 14 July 2011 may have been by that stage overcome.

Circumstances had changed. It was evident that Mr Harding-Roots may have been stalking her. A statement should have been taken from her in relation to the entire history of her relationship with Mr Harding-Roots on, or very soon after, 14 July

2011. There was a perfectly viable alleged offence to be investigated and it was an offence that required investigation regardless of Ms Rankine’s attitude.

5.43. The issues as to when it was that Ms Crisp had for the first time committed herself to paper about the 18 June incident, whether Vallo and Crisp had communicated with each other about the Rankine / Harding-Roots imbroglio and what was said and determined if anything about what should be done about it and, importantly, whether police intervention at that time may have altered the outcome were matters that were accorded scant attention during the investigation into this death.

5.44. If there was any doubt as to whether Mr Harding-Roots had made the calls to Harbour Town during the afternoon of 14 July 2011, telephone records obtained for the first time during the course of the Inquest revealed that a landline number in the name of Jeremy Roots was used to call the Harbour Town landline number that day at 3:16pm and 4:42pm respectively, the calls lasting 456 seconds in the first instance and 332 seconds in the second125. I observe that Ms Vallo’s ancillary report that was uploaded to the system at 2138 hours on 14 July 2011 cites the home telephone number of Mr Harding-Roots as the same number from which the two calls originated. I have no doubt that as of that date this was his home telephone number and that Mr HardingRoots was responsible for the two calls recorded made to the Harbour Town number on the afternoon of 14 July. I infer that the telephone records in question reflect the two calls that Mr Harding-Roots made in which he misrepresented that he was a police officer. Ms Vallo’s ancillary report also establishes that police were aware that the number had a connection with Mr Harding-Roots.

125 See Transcript, page 821 and Exhibits C114, C96p and C98a

5.45. There is one other matter that should be mentioned. An accusation was levelled at Ms Rankine that in the days prior to Mr Harding-Root’s death that she had been making harassing calls to Mr Harding-Roots. It was suggested by counsel for the Commissioner of Police that there was some evidence through the writings of Mr Harding-Roots in preparation for his suicide that he was asserting, from the grave as it were, that in the days prior to his suicide he had been harassed by Ms Rankine on the phone, using phone boxes from which to call him, including a call on Wednesday 20 July 2011 in which he asserted that she said that she had wanted to see him kill himself and that she would in the event get to see him die. What is evident is that Mr Harding-Roots’ assertion in a letter that he wrote to Mr Jon North, in contemplation of his own death, suggested that he had changed his landline telephone number because he was sick of all the calls from Ms Rankine. This apparent change of number occurred on or about 18 July 2011. Material attached to the affidavit of Detective Brevet Sergeant Anthony van der Selt indicates that on that date Mr Harding-Roots made an enquiry of Telstra in order to change his landline number because he was receiving nuisance calls from an ex partner. He had stated that he did not want to proceed with the change until he could sort the matter out with his ex partner to see if she would stop the harassment. I am not in a position to make any finding about that as an allegation as it does not assist me to analyse the issues with which this Inquest is concerned. I would simply make the observation that if Ms Rankine had been harassing Mr Harding-Roots, and was thereby inflaming an already heated situation, the need for police intervention after 14 July 2011 was even more acute. The assertions in these letters are those of a man who was contemplating suicide and who on his own admission was at one point in time obsessed with her.

The changing of a telephone number would not necessarily be indicative of a need to prevent her from harassing him. It is equally consistent with a ham-fisted attempt on his part for whatever reason to conceal the fact that he had been the person who had telephoned Harbour Town three days earlier. We will never know what motivated Mr Harding-Roots to say what he said in his departing letters, nor of what his underlying reasons were for doing such things as changing telephone numbers. The matters are of very limited relevance in any event.

5.46. In the opinion of the Court the following police action should have taken place on, or soon after, the 14 July 2011 incident: Ms Vallo should have created a police incident report in relation to the  information that was supplied by Ms Rankine on the evening of 14 July 2011 that identified a suspected offence of impersonating police contrary to section 74 of the Police Act 1998 and that Mr Jeremy Harding-Roots was a suspect in the commission of that offence; By 14 July 2011 a report in respect of the 18 June 2011 incident, whether it  consisted of an ancillary report or a police incident report, should have been posted to PIMS and have been available for scrutiny by Ms Vallo; In any case, the information supplied by Ms Rankine on 14 July 2011 should have  been considered in conjunction with what was known about, and should have been recorded about, the 18 June 2011 incident; A full statement should have been taken from Ms Rankine in respect of her  association with Mr Harding-Roots, including but not limited to an account of the events of 18 June 2011 and the events of 14 July 2011; A risk assessment should have been conducted in respect of the information that  Ms Rankine had supplied; Ms Rankine’s complaint that Mr Harding-Roots was suspected of having sought  information about her and about her current partner by means of impersonating a police officer should have been the subject of police investigation without undue delay. Such an investigation should have included, but not have been limited to, an attempt to interrogate Mr Harding-Roots about the matter as well as an investigation into the telephone accounts registered to him and to Harbour Town.

The recipient of the two calls made to Harbour Town, Ms Melanie Arthur, should have been identified and a statement taken from that person; If it was considered that there was insufficient evidence on which to arrest Mr  Harding-Roots for impersonating police, Mr Harding-Roots at least should have been warned of the consequences of any further approaches, direct or indirect, to Ms Rankine.

5.47. One thing is certain and that is that there was absolutely no defensible basis on which police could do nothing about the information that had been supplied by Ms Rankine in respect of Mr Harding-Roots.

6. SAPOL management of the 24 July 2011 incident 6.1. Before dealing with the police involvement in the incident in which Mr HardingRoots died, it is necessary to further discuss the evidence of the pathologist, Dr Langlois. Dr Langlois’ original post-mortem report126 does not refer to an approximate time of death in respect of Mr Harding-Roots. As explained in that report, for sound reasons Dr Langlois did not attend the scene.

6.2. In a supplementary report dated 21 August 2014127 Dr Langlois refers to the South Australian Ambulance Service (SAAS) record which indicated that rigor mortis was commencing in the limbs of Mr Harding-Roots when he was examined at 11:15 on the morning in question. Dr Langlois states that this is in keeping with death having occurred at any time between 7am and 9am, but would suggest that death had occurred closer to 7am than 9am. He would not attempt to provide any estimate of an actual time of death based on the condition of Mr Harding-Roots’ body at autopsy.

6.3. Following the provision of the supplementary report, counsel for the Commissioner of Police and counsel assisting requested Dr Langlois to consider further information that might be relevant to the time of death. In particular, Dr Langlois was asked to consider the following material:  The statement of SAAS rescue paramedic, Robyn Rooke128 that included observations of Mr Harding-Roots upon her entry to the premises at about 11:15am, including that the deceased was cyanotic, his face was pale and his lips were of a bluish colour. His body was rigid which was considered to reflect onset of rigor mortis. There was no chest movement and no evidence of breathing. His jaw was stiff with no pliability of the jaw. The pupils were fixed and dilated and the eyes were open. There was no capillary refill in chest and hand. Mr HardingRoots was deceased, and life was declared extinct at 11:15am; 126 Exhibit C2a 127 Exhibit C108 128 Exhibit C13a

The statement of Senior Constable Charles Theakstone of the SAPOL Explosive  Coordination Section129 who, with Senior Constable David Fox and SAAS officer Rooke, entered the premises at about 11:15am in which Mr Theakstone made observations of the deceased that were consistent with those of the SAAS officer Rooke;  The statement of Senior Constable David Fox, a SAPOL bomb technician130 in which Mr Fox made similar observations to those of Mr Theakstone.

6.4. Dr Langlois further reported that the information did not cause him to alter his opinion in relation to time of death. Accordingly, Dr Langlois’ evidence is that in his opinion Mr Harding-Roots’ death occurred between 7am and 9am on the morning in question, but that his death had occurred closer to 7am than 9am.

6.5. In the event, as already indicated, police and ambulance personnel did not enter the premises until 11:15am. He was found deceased lying on a bed. There had been an earlier observation of Mr Harding-Roots via a window at 10:51am. He had been unresponsive and in the same position. Police had been on the scene since approximately 7:15am and Mr Harding-Roots had last been observed placing a warning sign on a window at 7:25am. Officers situated close to the premises believed that they heard something within the premises at approximately 9am. It is not clear whether this was a noise made by Mr Harding-Roots. No other person was in the premises at that time.

6.6. There had been constant attempts to communicate with and negotiate with Mr Harding-Roots almost from the time of the arrival of police. No response had been elicited at any time. Other activity, that included the shutting down of utilities to the unit at 9:54am, had also failed to elicit a response from inside. In reality there was no evidence that Mr Harding-Roots was alive after 9am, on the assumption that the noise heard from within the premises was made by him. Dr Langlois would prefer the view that Mr Harding-Roots was probably already deceased by that time.

6.7. Taking everything into consideration I am of the view that Mr Harding-Roots was alive at the latest at 9am, and that he probably died some significant period of time prior to that.

129 Exhibit C57a 130 Exhibit C58a

6.8. This issue is of some significance in that any delay in police entering the premises between the hours of 9am and 11:15am, when Mr Harding-Roots was confirmed deceased, was of no moment or consequence. This had the effect that the Court did not see a need to scrutinise the quality of the police involvement between those hours as thoroughly as it might otherwise have had to do. That said, there was a great deal of evidence placed before the Court setting out in minute detail an account of the events as they unfolded from start to finish. I have carefully scrutinised all of that evidence. I need only refer to the salient features of that evidence.

6.9. Mr Harding-Roots’ entry of the premises occurred at about 7am. He had been dropped off by a taxi in a nearby street at about 6:52am. Ms Rankine and Mr Neailey had escaped the premises by 7:15am. At approximately 7:15am the initial police patrol comprising two officers arrived at the location and liaised with Ms Rankine and Mr Neailey. These officers, namely Constable Thomas and Probationary Constable Corfield of Sturt Patrols, initially made an attempt to establish contact with Mr Harding-Roots who was at that time ensconced in the premises. Messrs Thomas and Corfield quickly recognised the potential danger to other residents and evacuated all of the occupants from the other units of the complex.

6.10. At about 7:25am Messrs Thomas and Corfield observed the right hand of Mr Harding-Roots appear at the lounge room window from behind a curtain. The hand was holding a knife. The hand placed a Fumitoxin warning label on the inside of the window and affixed it with tape. The hand then disappeared from view. That was Mr Harding-Roots’ first and last sighting by police. Constable Thomas continued to attempt to make contact with Mr Harding-Roots for some 90 minutes until relieved at about the time that STAR Group established an inner cordon at 9:21am. In the meantime the matter had been identified as ‘high risk’ and various police procedures including the setting up of cordons and the establishment of command posts had been instigated.

6.11. The STAR Group Tactical Command arrived on the scene at about 8:40am with other STAR members. Aside from the several reports that have been prepared in relation to the sequence of events that have been tendered to the Court, the Tactical Commander, Inspector Wall, gave extensive oral evidence at the Inquest.

6.12. Prior to hearing from Inspector Wall the Court was concerned to identify why it had taken some four hours from the time of the arrival of the first police patrol to the entry of the unit was entered at 11:15am when Mr Harding-Roots was discovered already deceased.

6.13. Firstly, there is no question but that in all of the circumstances it would have been highly inappropriate for police to have forced the issue by entering the premises at any stage prior to the arrival of the STAR Group and of the specialist expertise and equipment that arrived with that Group. The mobilisation of STAR Group obviously took some time. Secondly, to my mind Mr Harding-Roots was in any case probably already deceased by the time STAR Group arrived at 8:40am.

6.14. In his evidence Inspector Wall explained that this situation was quite unique in police experience, both in this State and elsewhere, involving as it did a siege situation involving the use of chemicals. He explained that it was not simply a matter of officers entering the premises in an endeavour to quell the situation and if possible to rescue the occupant of the premises at a time before he decided to take steps to end his own life. There were many factors to be taken into consideration, including the safety of his own officers and the need to conduct a detailed risk assessment before any action involving an invasion of the premises or the use of force by his officers could be contemplated. As well, the safety of the wider general public needed to be carefully considered having regard to the potential that the deployment of the chemical weapon in question might not be contained to the premises in which it would deployed. In addition, there was a need to attempt to communicate with and negotiate with the occupant of the premises in an effort to secure an outcome that did not require force. The lack of any response on the part of the occupant did not in itself signify that the occupant was not still alive and capable of an adverse reaction if the premises was entered by police.

6.15. Having regard to all of the material that has been tendered to this Court in respect of the handling of the incident by police, and the evidence of Inspector Wall in particular, the Court was satisfied that no police activity or any omission or delay contributed to Mr Harding-Roots’ death. Any delay that existed was due to operational needs, was not excessive and has been explained adequately in all of the circumstances. In addition, there is nothing that the police or other services could

have done that would have prevented Mr Harding-Roots’ death without having exposed police personnel to an unacceptably high risk of harm.

6.16. Accordingly, the Court has not found it necessary to embark upon any detailed analysis of the police activity from the time of their arrival until the time of discovering Mr Harding-Roots deceased in the premises.

7. Was Mr Harding-Roots’ death preventable?

7.1. One matter that has to be carefully considered in this regard is the fact that even before 24 July 2011 Mr Harding-Roots evinced a strong determination to end his own life. I have already referred to the steps that he took to finalise his affairs. These included divesting himself of a substantial sum of money in respect of his funeral arrangements and the depositing of a gift of cash to his estranged wife. It will be noted, however, that much of this behaviour occurred between 14 July 2011 and the day of his death which occurred ten days later. It is apparent that in that period of time Mr Harding-Roots was residing at the Para Hills West address. There is no reason to think otherwise. There appears to have been no reason why, if police had identified Mr Harding-Roots as a suspect in the commission of a serious offence of impersonating police, he could not have been approached about that matter. He could have been located. He was still working at his place of employment. It is not certain, however, what Mr Harding-Roots’ reaction would have been to such an approach, particularly if it had involved an attempt on the part of investigating police to interrogate him about that matter. He may or may not have made admissions in relation to the issue as to whether he was the man who had made the bogus calls. It has to be acknowledged that if Mr Harding-Roots had not made any admissions in relation to his having been the perpetrator of the bogus calls that were made on 14 July 2011, it may have been difficult to justify an arrest prior to 24 July 2011. There was no evidence before the Court as to how readily the telephone records in respect of Mr Harding-Roots’ landline and/or the telephone records of Harbour Town could have been obtained. It will be observed that these records were for the first time obtained during the course of this Inquest, some three years after the event. If the records had been obtained before 24 July 2011, the day of Mr Harding-Roots’ death, there would have been a case against him of some considerable weight for which he undoubtedly could have been arrested. If so, an appropriate bail condition would no doubt have included a prohibition that he not approach Ms Rankine or attend at her

premises. If not arrested, then certainly police intervention in the form of an approach by them to Mr Harding-Roots would have at least put him on notice that his behaviour in respect of Ms Rankine was the subject of police scrutiny. Whether this would have overcome Mr Harding-Roots’ determination to go ahead with his sinister objectives on the day of his death cannot be known for certain. It is unlikely that Mr HardingRoots would have been kept in custody and not on bail if he had been arrested following the 14 July 2011 incident, but if he had approached Ms Rankine following his release, he would have been in breach of his bail conditions and subject to arrest and probable remand in custody.

7.2. In my view there were opportunities for legitimate police intervention in what had developed between Mr Harding-Roots and Ms Rankine. Whether such intervention would have deterred Mr Harding-Roots from ultimately taking the decision to end his life is a matter of conjecture, but there is also the possibility to be considered that at the very least he may have been deterred from taking homicidal action towards Ms Rankine and her partner which, in my view, was part and parcel of his objective of 24 July 2011.

7.3. The Court passes no comment as to whether in all of the circumstances that existed on or after 14 July 2011 a restraining order would have been granted by the Courts, but the request for the same made by Ms Rankine would have acted as further impetus for the police to investigate her complaint.

7.4. As indicated earlier, in my view there is no basis for saying that on 24 July 2011 any action on the part of police at the Warradale scene would have prevented Mr HardingRoots’ death.

8. Conclusions 8.1. The Court reached the following conclusions.

8.2. Ms Mandy Rankine and Mr Jeremy Harding-Roots had been in an intimate relationship that ended in 2011. Mr Harding-Roots failed to accept that the relationship was finished. Mr Harding-Roots became fixated on Ms Rankine and the fact that she had developed a relationship with another man.

8.3. On 18 June 2011 Mr Harding-Roots used a key to open the screen door at Ms Rankine's unit at Warradale. The key had been retained from his relationship with her. Ms Rankine physically resisted Mr Harding-Roots’ attempt to enter the unit by pushing against the unit door. Mr Harding-Roots overcame that resistance and forced the door open, causing Ms Rankine to stumble onto a seat. Mr Harding-Roots then entered the unit and while in the unit took a set of Ms Rankine’s keys which he then deposited in her letterbox. As this was taking place Ms Rankine was yelling at Mr Harding-Roots to leave the premises. Mr Harding-Roots left the premises.

Mr Harding-Roots’ entry into the premises constituted the offence of criminal trespass contrary to section 170A of the Criminal Law Consolidation Act 1935. Following the incident Ms Rankine’s partner, Mr Daniel Neailey, attended at the premises and telephoned Police Communications. It is clear that he advised police that Mr Harding-Roots had forcefully entered the premises against the will of Ms Rankine, in the course of which she was knocked over. He also advised police that Mr Harding-Roots had taken her keys and that the complainant was shaken by this incident.

8.4. Senior Constable Crisp and Probationary Constable Schumacher of SAPOL attended at the premises that evening. I am uncertain as to whether Ms Rankine accurately informed the officers about the exact circumstances in which Mr Harding-Roots had managed to enter the premises beyond telling them that she did not want him to enter the premises. I find that Ms Crisp, who was taking the lead in this investigation, was either told about the forceful circumstances in which Mr Harding-Roots had entered the premises, or wholly failed to investigate the information that had been imparted to police by way of Mr Neailey’s telephone call to Police Communications, the details of which were contained in a CAD display in the officers’ vehicle.

8.5. I find that when Ms Crisp spoke to Mr Harding-Roots on the telephone during the course of this incident, Mr Harding-Roots said words to the effect that he would kill himself. Ms Rankine told Ms Crisp words to the effect that Mr Harding-Roots habitually said that.

8.6. Ms Crisp was under an obligation to file a police ancillary report in relation to her attendance upon Ms Rankine’s premises. I find that Ms Crisp compiled a PD345 hard copy ancillary report on 15 July 2011. I am uncertain as to whether Ms Crisp had compiled any earlier iteration of that document. I very much doubt it. In any event,

no ancillary report relating to the 18 June 2011 incident was uploaded to the Police Incident Management System (PIMS) until 16 August 2011, which was approximately three weeks after the death of Mr Harding-Roots.

8.7. The failure to have the 18 June incident ancillary report uploaded to PIMS was a significant failing. It was egregiously overdue.

8.8. On 18 June 2011 I find that Ms Crisp warned Mr Harding-Roots of the consequences of continuing to harass Ms Rankine.

8.9. On 14 July 2011 Mr Harding-Roots telephoned the premises of Ms Rankine’s employer at Harbour Town on Tapleys Hill Road, West Beach. In both conversations Mr Harding-Roots falsely said that he was a police officer. Mr Harding-Roots’ motive in initiating these calls was to establish Ms Rankine’s movements and possibly her whereabouts and also to establish the identity of her current partner. It may also be the case that Mr Harding-Roots was endeavouring to sully Ms Rankine’s character in the eyes of her employer by suggesting that she was being investigated for the theft of cleaning products and the possession of drugs. That evening Ms Rankine reported to Senior Constable Vallo of SAPOL at the Sturt police station her belief that Mr Harding-Roots had been the initiator of the phone calls that had been received at Harbour Town that afternoon. I find that during Ms Rankine’s attendance at the Sturt police station she enquired about the possibility of obtaining a restraining order against Mr Harding-Roots but was told in effect that it was not possible.

8.10. Ms Vallo compiled an ancillary report in relation to the information that Ms Rankine had imparted to her. The ancillary report was uploaded that evening to PIMS. The compiling and uploading of an ancillary report was not the correct way of dealing with the information that had been imparted to police. Ms Rankine’s complaint had identified the alleged commission of an offence of impersonating police contrary to section 74 of the Police Act 1998. As well, she had identified a suspect in respect of that alleged offence, namely Mr Harding-Roots. A police incident report in relation to the information imparted by Ms Rankine should have been compiled and the alleged offence that is disclosed should have been investigated without undue delay.

Investigations should have included an approach to Mr Harding-Roots by police to establish whether or not he was the perpetrator of the alleged impersonation of police.

An attempt should have been made to retrieve relevant phone records.

8.11. On or about 14 July 2011 police should have examined the information imparted by Ms Rankine in respect of the Harbour Town phone calls in conjunction with the information that had been obtained through her in respect of the 18 June 2011 incident. A full statement should have been taken from Ms Rankine in relation to her relationship with Mr Harding-Roots and his behaviour since the relationship ended.

8.12. It was not an option for police to have done nothing in relation to Ms Rankine’s complaint of 14 July 2011. It cannot be known for certain whether police intervention with Mr Harding-Roots soon after 14 July 2011 would have completely deterred him from embarking upon his homicidal and suicidal behaviour on 24 July 2011, but it is conceivable at least that police intervention may have interrupted the chain of events that led to Mr Harding-Roots’ death.

8.13. On 24 July 2011 Mr Harding-Roots again entered the Warradale unit of Ms Rankine.

Ms Rankine and Mr Neailey were on the premises. Mr Harding-Roots entered the premises with a container of Fumitoxin which is a noxious and potentially fatal substance. Mr Harding-Roots’ objective was to take the life of at least Ms Rankine and probably Mr Neailey, and to end his own life as well. Fortunately Ms Rankine and Mr Neailey were able to escape the premises and notify police. Police attended the scene. I find that there is nothing that police could have done at the scene which would have prevented Mr Harding-Roots’ death. I find that Mr Harding-Roots took his own life at a time well before police could reasonably have been expected to mobilise and put in place the necessary resources to deal with the situation. No police act or omission that day contributed to his death.

9. Recommendations 9.1. Pursuant to Section 25(2) of the Coroners Act 2003 the Court is 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 Inquest.

9.2. The Court has been supplied with the affidavit of Detective Superintendent Graham Goodwin131 in which police procedures in respect of the compilation, vetting and uploading of a process known as ‘SHIELD’ which contains a number of options that replace the old ancillary report system, are described. The affidavit indicates that at 131 Exhibit C113

the time with which this Inquest is concerned General Orders did not specify timeframes for the submission of an ancillary report, except in certain circumstances that did not apply here. I do not see the need to make any recommendation about operational matters of that nature.

9.3. It is worthwhile making the observation that SAPOL General Order Domestic Violence probably did not apply to the situation that presented itself to police in June and July of 2011. To my mind this contributed to the consequence that no police action was taken in relation to the situation that had developed by 14 July 2011 between Ms Rankine and Mr Harding-Roots. If that situation had been encompassed with the operation of the General Order, it would have triggered certain measures regardless of whether an actual criminal offence had been identified, including the compilation of a formal Domestic violence risk assessment and Domestic violence risk management plan. Yet the situation that had developed was potentially every bit as volatile as the domestic situations contemplated within that General Order. As well, behind the scenes Mr Harding-Roots was experiencing what could only be described as an emotional meltdown. This Inquest has demonstrated that in cases that involve emotionally charged situations such as that which existed between Ms Rankine and Mr Harding-Roots there is a need to carefully consider and assess risk of escalation and to enquire beyond what is apparent on the surface. The evidence has demonstrated that much relevant information may lie under the surface of any complaint such as that made by Ms Rankine on 14 July 2011. I refer here to the activities and behaviour of Mr Harding-Roots in respect of preparations he made for his own death and also statements he made to his estranged wife, Ms Lynn Harding-Roots. And clearly, when a criminal offence has been committed there is an acute need for a matter such as the present to be investigated at the first available opportunity.

9.4. I direct the following recommendations to the attention of the Commissioner of Police.

9.5. I recommend, as the State Coroner has recommended in the matter of the death of Mrs Zahra Abrahimzadeh, that all aspects of domestic violence policing be characterised by a sense of curiosity, questioning and listening. Risk assessment must be actually applied, not merely recited as a mantra.

9.6. I further recommend that in cases such as these, which for the purposes of SAPOL General Orders may not necessarily be characterised as involving violence or potential violence of a domestic nature, that all complaints of a similar nature be referred to police officers who have training in domestic violence risk assessment. At the very least, all such complaints should immediately be drawn to the attention of an officer of the rank of Sergeant or above.

9.7. I further recommend that within SAPOL General Order Domestic Violence the definitions of ‘Domestic partner’ and ‘Close personal relationship’ be amended to encompass circumstances akin to those that existed between Ms Rankine and Mr Harding-Roots.

9.8. I further recommend that police be directed to carefully consider whether in a complaint made in the context of a domestic situation involves the commission of a criminal offence. I further recommend that investigations into offences committed in that context be given priority.

9.9. I note the many recommendations that have arisen internally within SAPOL that relate to the improvement of management of incidents such as that of 24 July 2011.

Many of those recommendations, particularly those that are set out in the report and affidavit of Sergeant Peter Schar, concern means by which delay can be minimised. I have seen those recommendations and I would endorse them. I see no need to add any further recommendations of the Court.

Key Words: Phosphine; Death in Custody; Suicide In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 24th day of June, 2015.

Deputy State Coroner Inquest Number Inquest 11/2014 (1159/2011)