Coroner's Finding: HENEKER Scott Maxwell

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 29th day of April 2016 and the 22nd day of September 2016, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Scott Maxwell Heneker.

The said Court finds that Scott Maxwell Heneker aged 36 years, late of 22 Sugarbush Road, Reynella, South Australia died at the Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia on the 7th day of August 2012 as a result of hypoxic ischaemic encephalopathy due to cardiac arrest occurring during restraint with possible contributing factors of meningoencephalitis consistent with a viral aetiology and amphetamine use. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for Inquest 1.1. Scott Maxwell Heneker was 36 years of age when he died on 7 August 2012. At the time of his death Mr Heneker was in the Flinders Medical Centre having been admitted in the early hours of 2 August 2012. Mr Heneker had suffered a cardiac arrest while he was being restrained by the owner of a house that Mr Heneker had entered without lawful permission. The owner had been awakened by his wife who had seen Mr Heneker standing in the doorway of their bedroom. The house owner, Mr Glassman, proceeded to physically restrain Mr Heneker by pinning him to the ground while his wife contacted emergency services. Mr Glassman restrained Mr Heneker by placing himself on top of Mr Heneker until help arrived.

1.2. Mr Glassman was exercising his rights at common law to detain an intruder on his property, and accordingly Mr Heneker may be regarded as having been detained

pursuant to a law of the State at the time when the cardiac arrest that ultimately triggered the medical events leading to his death occurred. Mr Heneker’s death was therefore a death in custody within the meaning of that expression in the Coroners Act 2003 and this Inquest was held as required by section 21(1)(a) of that Act.

2. Cause of death 2.1. An autopsy was performed by Dr Karen Heath, forensic pathologist from Forensic Science South Australia, who provided a report1 giving Mr Heneker’s cause of death as hypoxic ischaemic encephalopathy due to cardiac arrest occurring during restraint with possible contributing factors of meningoencephalitis consistent with a viral aetiology and amphetamine use, and I so find.

2.2. At autopsy Dr Heath noted, in addition to the findings referred to above, a track mark in the right upper arm and moderate coronary artery atherosclerosis in the proximal left anterior descending coronary artery. The toxicological findings from analysis of a specimen of blood obtained on admission to the Flinders Medical Centre showed 0.078mg/L of methylamphetamine and 0.09mg/L of amphetamine2. Other drugs were not detected. These concentrations of methylamphetamine and amphetamine are consistent with illicit use. Dr Heath said it is possible that the presence of the amphetamine in Mr Heneker’s system had a bearing on his behaviour at the time he entered the Glassman’s house and may also have increased the likelihood of cardiac arrhythmia and subsequent cardiac arrest during a period of physiological stress.

Dr Heath was unable to express an opinion with any certainty as to the relevance of the meningoencephalitis, noting that it might have been present prior to the physical confrontation, or it may have been developed in the days following that event during Mr Heneker’s hospitalisation.

3. Background 3.1. Mr Heneker had employment as a sales person and had worked in that occupation since leaving school. In October 2011 Mr Heneker met Anita Graham with whom he started a relationship. Her evidence is contained within her statement3. She said that Mr Heneker had not been diagnosed with any illnesses, but it was possible that he 1 Exhibit C2a 2 Exhibit C3a 3 Exhibit C15a

suffered from depression. He did not seek medical treatment and had not had any official diagnosis by a medical practitioner. His mother had been diagnosed with schizophrenia some 22 years prior to Mr Heneker’s death. He would on occasions obtain Seroquel and Valium from his mother who apparently had been prescribed those drugs.

3.2. In the months leading up to Mr Heneker’s death Ms Graham had noticed a change in his behaviour. From December 2011 they had been having minor arguments and Mr Heneker’s behaviour became increasingly erratic and frantic to the stage where Ms Graham thought he may be suffering schizophrenia and taking illicit drugs. He resisted her requests to seek medical assistance. She referred to an occasion when she was with Mr Heneker in the presence of a third person who had asked if she and Mr Heneker wanted to go to Glenelg to collect an ‘eight ball’ (amphetamine). The person who had suggested that Mr Heneker and Ms Graham might wish to obtain an ‘eight ball” was interviewed by police. He stated that Mr Heneker had contacted him and asked him to obtain drugs for him, but that he had not done so. He said that he was aware that Mr Heneker took drugs (mostly amphetamines) but claimed that he was not aware of the source of those drugs.

3.3. Ms Graham said in her statement that she received a telephone call at 10:35pm on 1 August 2012. The call was from Mr Heneker. He said that he wanted her to pick him up straight away because there were police all over his yard and his house and he was ‘freaked out’. He said that he was using a neighbour’s phone and that it took him ages to find a neighbour that would lend him one. He also told her that he had been knocking on doors but no one would let him in. She said that Mr Heneker sounded panicky and frantic. Ten minutes later she received a second call from Mr Heneker, this time from a different number. He was asking her where she was and was talking about police being in his front yard. She told him that she was coming to get him. She then drove from her house to Mr Heneker’s house and on arriving she parked outside. She looked in the front of the house and could see Mr Heneker’s shadow within. She said that it looked as if he was running. She then saw the front sensor light come on and Mr Heneker came out of the front gate. He was not wearing any pants and he was pulling his jumper down to cover himself. Ms Graham said that there were no police in sight at all. Mr Heneker signalled for her to come inside but she shook her head and signalled for him to come to the car. He waved his arms about and went back into the

house for a minute or two. He came back out with pants on and his dog. He put the dog on the back seat of her car and then got into the front passenger seat. He said for her to ‘just go’. She asked him what was wrong. He started crying and said words to the effect ‘they’re setting me up, they’re trying to kill me’. When she asked who he was referring to he said ‘all of them, the neighbours and others’. He then looked at her and said words to the effect ‘oh my God you’re in on it too aren’t you’ and then started sobbing that he was dead. She said for him to calm down and drove the car away from his house. He asked her not to take him to hospital. She told him to calm down and decided not to take him to hospital because she was worried about what he might do while she was driving there. Mr Heneker asked her to drive him to his mother’s house and she agreed. When they arrived Mr Heneker went to the front door but his mother did not answer. Mr Heneker used his key to get in but found that his mother was not home. He returned to the car and then claimed that his mother was ‘in on it too’.

Mr Heneker said that he did not know what to do and Ms Graham suggested that they go to the police station where he would be safe and they could sort things out.

Mr Heneker agreed, but asked if Ms Graham thought the police would believe him.

She convinced him to go.

3.4. When they arrived at the Sturt Police Station they approached the front desk and were asked by an officer how they could be assisted. Mr Heneker told her that he thought he was being set up. He was talking very fast and jumping from one topic to another. The officer said that he was not making sense and asked him what he had taken. He told her he had taken some speed. The officer asked Ms Graham if she had taken anything and she said no. Ms Graham provided her personal details. She said that Mr Heneker should go home and not take speed ever again. Mr Heneker then said words to the effect of ‘I’m just being silly aren’t I?’ and agreed that he would never take speed again.

The police officer also suggested that Mr Heneker should see a general practitioner the next day. After this Mr Heneker seemed to have calmed down a lot and they returned to Ms Graham’s car. He said he would like to go back to his mother’s house.

Ms Graham took him there but his mother was still not home and it was decided that Ms Graham would drive Mr Heneker back to his own house. This she did and left. The next day she heard that Mr Heneker was in the Intensive Care Unit at the Flinders Medical Centre4.

4 See Exhibit C15a

4. The events of 2 August 2012 4.1. Mr Glassman told police that he was in bed with his wife in the early hours of 2 August 2012 when they heard noises. It was Mr Glassman’s wife who was woken to start with.

She heard the sliding door to the house being opened and then she saw a man standing in the doorway of the bedroom. She screamed. Mr Glassman then instinctively ‘went at’ Mr Heneker. There was a fight of some kind, but Mr Glassman managed to restrain Mr Heneker in the kitchen by pinning him to the floor. Mr Glassman’s account was that he was sitting on Mr Heneker’s chest trying to restrain his arms because Mr Heneker was punching at Mr Glassman5.

4.2. A Triple Zero call was made by Mrs Glassman at 1:52am. Patrols arrived at 1:54am having been in the area as a result of disturbances that had been reported from neighbours. Ambulance officers were on the scene by 2:03am having been summoned by police.

4.3. The first two police officers on the scene were Officers Petersen and Macrow. They noted that there was some blood in the kitchen which was from Mr Heneker and it had come from a very deep cut to his thumb and hand. Police later established that this had been sustained not in the struggle with Mr Glassman, but in Mr Heneker’s activities before arriving at the Glassman house6. However, Mr Glassman did have some injuries as a result of the confrontation with Mr Heneker, namely facial injuries and some bruising. Mr Glassman said that he had been punched quite a few times and had been kicked to the face by Mr Heneker7.

4.4. Officers Macrow and Petersen entered the kitchen and observed Mr Glassman on top of Mr Heneker. As they entered Mr Glassman got off Mr Heneker and left the kitchen area. The police officers immediately thought that there was something wrong with Mr Heneker because his eyes were half open and he did not appear to be responsive.

They checked for a pulse and could not find one. Constable Macrow stated that Mr Heneker’s eyes were wide open and he could hear a gurgling sound. The officers then commenced first aid8. As I have already said, ambulance officers arrived a short time later.

5 See Transcript, page 35 6 See Transcript, page 41 7 See Transcript, page 42 8 See Transcript, page 64

4.5. I have listened to the Triple Zero call made by Mrs Glassman to the police.

Mr Glassman can be heard in the background. It is clear that Mr Glassman was in some physical distress. He was panting and plainly involved in some kind of a situation with another person. He was asking for someone to come quickly. He was heard to say that he did not know how much longer he could hold on to the intruder and he was clearly fearful about what was going on.

4.6. The opinion of the investigating officer, Detective Brevet Sergeant McPherson, was that Mr Glassman had not used excessive force in detaining Mr Heneker9. This was also the opinion of the Director of Public Prosecutions who concluded that no offence had been committed by Mr Glassman10.

5. SAPOL investigation 5.1. Senior Constable McKay is a crime scene investigator and he provided a statement to the Inquest11. He examined the Glassman property and Mr Heneker’s property and the areas between those two addresses. As it happens, the two properties are only some eight properties apart in the suburb of Reynella. After studying evidence located at various sites between the two properties, Senior Constable McKay reconstructed the events and concluded that Mr Heneker had left his home address at 22 Sugarbush Road and walked to Tamarac Place. He then entered a property at 15 Tamarac Place and climbed over the side gate cutting his hands on the uncapped iron sheets. He then walked through the rear yard of 15 Tamarac Place and climbed over the boundary place between that property and 8 Sugarbush Road, Reynella, leaving blood on top of the fence and the suspended swing seat in the rear yard of 8 Sugarbush Road. He then walked across the read yard of 8 Sugarbush Road and into the carport where he attempted to climb over the side gates to gain access back onto Sugarbush Road. He was unable to do so due to the height of the gate (which was 1.8 metres) and the position of the horizontal drain pipe above. It was then that he entered the dining room of the house via the sliding glass door leading from the carport area. It seems likely that the Glassman’s had inadvertently left that door open12. Senior Constable McKay had concluded that Mr Heneker cut his hands on the fences referred to because of evidence 9 See Transcript, page 44 10 See Transcript, pages 44-45 11 See Exhibit C30a 12 See Exhibit C30a

discovered on those fences, and he also noted that there was no blood at Mr Heneker’s house13.

5.2. The investigation showed that between approximately 10pm and 11pm Mr Heneker had approached two sets of neighbours in an agitated manner. These were the neighbours whose assistance Mr Heneker had sought in contacting Ms Graham. He was then taken by Ms Graham to the Sturt Police Station before being returned to his house. The next piece of information about his movements was a call to Triple Zero by a neighbour, Ms Parini, at approximately 1:30am. She reported that she could hear someone at the front of her house calling for help14. The next contact was the Triple Zero call from Mrs Glassman at 1:52am15.

6. Conclusion 6.1. It is reasonably apparent from the circumstances leading up to Mr Heneker’s death that he was suffering from an undiagnosed mental illness or that he was certainly showing signs and symptoms consistent with a mental illness. On the other hand he had been maintaining employment and did have a lengthy employment history. Unfortunately, it appears that he had been consuming methylamphetamine and it is this that led to his bizarre behaviour on the night in question. It would seem that he had become paranoid and delusional forming the view that the police had surrounded his house and were out to get him. He made attempts to get help from neighbours who he approached in a very odd manner and asked to use their phones. He was observed by them to be making phone calls asking someone to come and get him. He was then taken by Ms Graham to the Sturt Police Station and returned home. He was heard to have been calling for help by Ms Parini at approximately 1:30am and after that appears to have returned to his house before leaving again, going through a park, over a road, over a gate where he has cut himself and ultimately arrived in the Glassman premises in a state of high agitation.

6.2. I accept the submission of counsel for Ms Graham that it is by no means clear that Mr Heneker had entered the Glassman household in order to commit an offence. It is possible that he was acting under a paranoid or delusional belief that he was being pursued and was trying to escape from a perceived danger. He then had his 13 See Transcript, page 53 14 See Transcript, page 58 15 See Transcript, page 58

confrontation with Mr Glassman which most unfortunately resulted in a cardiac arrest and his subsequent death.

6.3. I agree with the opinion expressed by the Director of Public Prosecutions that Mr Glassman did not commit any offence and that Mr Heneker’s death was a result of a tragic set of circumstances that unfolded on the night in question.

7. Recommendations 7.1. I have no recommendations to make in this matter.

Key Words: Death in Custody; Psychiatric/Mental Illness; Amphetamines In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 22nd day of September, 2016.

State Coroner Inquest Number 10/2016 (1306/2012)