Coroner's Finding: BRADLEY Dwayne Scott

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 6th day of May 2016, the 13th day of July 2016 and the 1st day of August 2016, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Dwayne Scott Bradley.

The said Court finds that Dwayne Scott Bradley aged 25 years, late of 5 Heathcote Street, Normanville, South Australia died at 5 Heathcote Street, Normanville, South Australia on the 22nd day of July 2014 as a result of hanging. The said Court finds that the circumstances of his death were as follows:

1. Introduction 1.1. Dwayne Scott Bradley was 25 years of age when he died on 22 July 2014. Mr Bradley was discovered hanging by the neck within a shed at his home address in Normanville.

He was found by his female partner. His partner managed to cut the rope by which the deceased was hanging. She then called the emergency services. Police and South Australian Ambulance Service personnel attended. Resuscitation attempts were unsuccessful and Mr Bradley was pronounced life extinct.

2. Cause of death 2.1. A post-mortem examination in respect of Mr Bradley was conducted by Dr Stephen Wills of Forensic Science South Australia. Dr Wills established that the cause of death was hanging. I find hanging to have been the cause of Mr Bradley’s death. At postmortem Mr Bradley had methamphetamine, codeine and ibuprofen in his blood.

Methamphetamine is an illicit substance. No illicit substances, including methamphetamines, were found in Mr Bradley’s home nor on his person. The amount

of codeine and ibuprofen detected in the deceased’s blood were reported to be consistent with therapeutic concentrations. Both drugs are analgesics.

2.2. It is obvious from the evidence, and I so find, that Mr Bradley was solely responsible for the act that lead to his death. Mr Bradley left only the briefest of notes to his partner.

It shed little light on the motivation underlying his suicide.

3. Reason for Inquest 3.1. At the time of his death Mr Bradley was the subject of home detention bail in respect of alleged offences committed in February 2013. Mr Bradley had yet to be tried in respect to those alleged offences.

3.2. Mr Bradley’s place of home detention was 5 Heathcote Street, Normanville where he resided with his partner. The act of hanging and his consequent death both occurred at those premises. By virtue of Mr Bradley’s home detention and the provisions of the Coroners Act 2003, Mr Bradley’s death was a death in custody. This meant that an Inquest into the cause and circumstances of his death was mandatory. These are the findings of that Inquest.

4. Background 4.1. Mr Bradley had been arrested on 15 February 2013 for, among other things, aggravated intentionally causing harm allegedly committed on 1 February 2013. On 25 February 2013 he was released on home detention bail with conditions that he wear an electronic monitoring device and reside initially with his mother at an address at Marjory Street, Normanville. On 21 October 2013 the residence condition of his home detention bail was altered to allow him to move to the Heathcote Street address in Normanville where he would live with his partner. Mr Bradley remained at that address until his death.

This was his place of detention.

4.2. Mr Bradley had a criminal history dating back to 2007. However, he had no recorded episodes of self-harm while in the custody of police or the Department for Correctional Services. He had not been the subject of a diagnosis of a mental health illness and had never been detained in a psychiatric facility. While on home detention bail between 25 February 2013 and 22 July 2014, Mr Bradley had a number of reported breaches of the conditions of his bail. Some of those breaches, involving alleged failed alcotests and an alleged unauthorised absence from the place of detention, became the subject of

prosecution. As well, he had been reported for driving whilst disqualified at Normanville on 18 January 2014 which if proven would also have constituted a breach of bail. The disqualification had been imposed in respect of an accumulation of demerit points. Mr Bradley was due to appear on those charges in the Victor Harbor Magistrates Court on 1 September 2014. These matters would have exposed Mr Bradley to the possibility of his home detention bail being revoked, but it is understood that no action was taken against him in that regard.

4.3. During the police investigation into Mr Bradley’s death, statements were obtained from his mother Ms Melissa Bradley and from his partner Ms Hannah Whitworth. I am informed that Ms Whitworth has since died from injuries sustained in a motor vehicle accident. Ms Bradley states that her son apparently had coped well on home detention bail. She considered that his relationship with Ms Whitworth was going well.

Mr Bradley never expressed to his mother that he was depressed or that his court proceedings were getting him down, and he gave her no indication that he was in such a state that he would self-harm or commit suicide. Ms Bradley’s last contact with her son was on the evening of Sunday 20 July 2014. At this time Mr Bradley had seemed upbeat and they had shared a laugh together. During that day Mr Bradley had been helping his sister by conveying her to and from her place of employment. Ms Bradley later received a voice message from her son telling her that he was at the jetty and asking her what she was doing. Again she describes his tone in that message as being upbeat.

4.4. Ms Hannah Whitworth had been in a relationship with Mr Bradley for approximately two years. They had cohabited for several months immediately prior to his death.

Ms Whitworth told investigating police that in July 2014 their relationship was going very well. She said that they had plans to marry and they were trying to conceive a child together. However, Ms Whitworth also indicated that she was of the belief that being on home detention bail had caused difficulty for Mr Bradley, insofar as it isolated him and limited his ability to undertake activities with friends, or even with Ms Whitworth herself outside of the confines of their home. She believed that the restriction of having to seek permission from home detention officers to do even simple things such as going to the shops was depressing him. Needless to say, such a regimen is an intrinsic element of home detention bail, and it must be remembered that the custodial alternative would have been much less palatable, a matter that Mr Bradley was no doubt alive to.

4.5. In her statement Ms Whitworth said that in April 2014 Mr Bradley appeared in court in relation to the charges for which he was on home detention bail. Court records show that the actual date was Monday 7 April 2014. On that day the case was listed for the commencement of the trial in the District Court. The trial was set down for five days.

The Court record reveals that the trial did not proceed that day because the case, to adopt the terminology of counsel and the Judge, was ‘not reached’. I presume this was meant to reflect that as a result of listing or resource exigencies there was no Judge to hear and / or no courtroom available to accommodate the trial despite the fact that it was listed, contingently or otherwise, to start that day. A fresh trial date of 1 September 2014 was suggested. In the event 13 October 2014, a date some 20 months since Mr Bradley’s arrest and placement on home detention bail, was set as the new trial date, a fixture that was set to suit both the court and Mr Bradley’s counsel.

4.6. In her statement Ms Whitworth reported that following the postponement of the District Court trial, Mr Bradley in her view became more depressed and that their relationship became more strained. Mr Bradley was worried about his court matters, about his finances and legal fees and about his inability to obtain steady work, due both to the restrictions that home detention bail imposed and to his isolation in Normanville which limited his capacity to obtain work. In the week leading up to his death Mr Bradley had obtained some work through his mother's partner.

4.7. Ms Whitworth also reported that shortly after the aborted District Court trial in April 2014 Mr Bradley said to her that perhaps it would just be easier if he died. He later recanted this, dismissing it as just a stupid comment. He assured her that he would never harm or kill himself. Ms Whitworth felt that Mr Bradley was depressed in the time leading up to his death and he expressed these feelings to her. However, he did not seek any medical attention in relation to this issue. There was no formal diagnosis in relation to depression and therefore no medication prescribed in relation to that.

There is no evidence that Mr Bradley nor any person intimately connected with Mr Bradley drew his unhappiness or the stressors associated with his home detention to the attention of community corrections staff. The two community corrections officers who dealt with Mr Bradley, namely Ms Mary Longbottom and Mr Justin Markham1, describe Mr Bradley respectively as ‘arrogant and cocky and he was generally argumentative and hard to get along with’, and ‘arrogant and surly’.

1 See Statements Exhibits C7 & C8 respectively

5. Mr Bradley’s death and the subsequent investigation 5.1. On the day of Mr Bradley’s death Ms Whitworth woke at about 8:15am to find Mr Bradley lying in bed next to her. She spoke to him briefly to tell him the time in case he had to go to work. He told her that he did not have to go to work that day so she went back to sleep. Ms Whitworth awoke again at about 9am and at that time she reports seeing Mr Bradley sitting at the table rolling a homemade cigarette. Again Ms Whitworth fell back to sleep and upon waking about an hour later at 10am she could not see Mr Bradley anywhere in the bedroom or in her immediate vicinity. She commenced looking for him around the house and ultimately out in the shed where she found him hanging from a rafter by a blue and yellow rope. She proceeded as quickly as she could to cut him down and commenced CPR while awaiting the arrival of emergency services. Unfortunately, despite aggressive CPR, Mr Bradley was declared deceased by an intensive care paramedic at 11:06am at the premises.

5.2. Mr Bradley’s death was investigated by Detective Brevet Sergeant Debra Penney of the Victor Harbor CIB. Ms Penney’s investigation and her report are extensive. I do not need to go into the detail of all of Ms Penney’s investigations and conclusions.

Ms Penney quite properly does raise a matter that involves an allegation made by Mr Bradley of an assault by police, presumably on the occasion of his arrest in February

2013. Ms Penney established that from certain medical notes in respect of the deceased it was identified that on 15 March 2013 the deceased reported to his local medical practitioner that he had been assaulted by police. This allegation was not reported to police and was not unearthed until the medical case notes were examined after the deceased’s death. No such allegation was made by Mr Bradley during a formal interview conducted upon his arrest on 15 February 2013. A bleeding injury to Mr Bradley’s right arm was noticed on that occasion, but Mr Bradley had indicated to police officers that the injury was a pre-existing burn that had occurred in a domestic setting. In short, there is no evidence to substantiate any allegation of assault by police at any time.

5.3. Ms Penney also noted that Mr Bradley had been afforded extensive pass out approvals by Department for Correctional Services personnel that included dog walking passes, exercise passes, lunch passes and passes to collect his sisters from school and work.

There were a number of alleged unauthorised absences from the place of detention, as noted by monitoring officers during monitored supervision, that for the most part

resulted in a verbal warning of the breach. There were occasional complaints made by the deceased that the monitoring system was falsely recording unauthorised absences from his place of detention. These matters were made known to police with the view taken that alleged breaches arising from these circumstances could not be proved.

However, I note that there were prosecutions on foot in relation to alleged failed alcotests and the drive disqualified alleged offence due to be heard at Victor Harbor on 1 September 2014, matters relatively easily proved. I do not know why these allegations did not trigger a revision of the attitude to Mr Bradley reamaining on bail.

5.4. Ms Penney makes the observation that the deceased had been under monitored supervision for a period of 19 months at the time of his death and that at face value this could be considered an excessive period of time. A more accurate figure is 17 months, but the point made is nonetheless valid. Indeed, as a result of Mr Bradley’s trial not being reached in April 2014, he would have been on monitored supervision for nearly 20 months by the time of its rescheduled commencement date in October 2014.

6. Recommendations 6.1. The Court does not see any need to make any recommendations in relation to this matter.

Key Words: Death in Custody; Home Detention; Suicide In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 1st day of August, 2016 Deputy State Coroner Inquest Number 21/2016 (1240/2014)