Coroner's Finding: AMOS Serina May

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 30th day of October 2018, the 4th, 5th, 6th, 7th, 10th, 11th, 12th, 13th, 20th and 21st days of December 2018 and the 27th day of March 2019, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Serina May Amos.

The said Court finds that Serina May Amos aged 34 years, late of 7 Ikaturka Terrace, Oodnadatta, South Australia died at Oodnadatta, South Australia on or around the 3rd day of July 2015 as a result of blunt force trauma on a background of contributing ischaemic heart disease. The said Court finds that the circumstances of her death were as follows:

1. Introduction 1.1. Serina Amos died on or around 3 July 2015 at Oodnadatta in South Australia. She was 34 years of age. An autopsy was conducted by Dr Langlois, consultant forensic pathologist at Forensic Science South Australia. In his post mortem report1 he gave the cause of death as blunt force trauma on a background of ischaemic heart disease, and I so find. Dr Langlois listed 56 injuries to her body. He said that there would have been significant blood loss from the cumulative effect of these injuries. He said that death due to blunt soft tissue trauma is an accepted phenomenon and the mechanism of death is believed to be hypovolemic shock resulting in organ failure which develops over the period of around a day.

1 Exhibit C3a

1.2. Ms Amos’ domestic partner at the time, Mr Danny Ferguson, was later found guilty by a jury to an alternative charge of manslaughter after pleading not guilty to the murder of Ms Amos. He was sentenced on 13 October 2016 by Vanstone, J in the Supreme Court. He was sentenced to 15 years imprisonment with a non-parole period of 12 years. Justice Vanstone, in her sentencing remarks, made reference to the evidence of Dr Langlois in the jury trial which she accepted. The evidence was that the injuries were inflicted over a period, in three tranches. Dr Langlois could not point to any particular injury as being critical, but he referred to ‘punched-out injuries’, suggesting a weapon was used, and a blood smeared tomahawk handle, which bore both Ferguson’s DNA and that of Ms Amos. Justice Vanstone saw this as an extremely serious case of manslaughter resulting from a prolonged period of violence and degradation and commented that Ms Amos must have died in a state of profound fear and pain and was powerless to get away from Ferguson who had inflicted the injuries.

1.3. Justice Vanstone also referred to the circumstances in which authorities were alerted to Ms Amos’ death. She said that Ferguson came into Oodnadatta with Ms Amos’ body in her vehicle. He then lied about what had occurred. He told several people, including Ms Amos’ sister and nurses at the Oodnadatta Clinic, that a man called Thomas Stewart had raped and bashed her. He also said that she had taken an overdose of pills. He claimed that he had evidence in a plastic bag which would provide evidence that Thomas Stewart had raped her. Justice Vanstone said that all of these statements were lies told in attempt to cast the blame for Ms Amos’ death elsewhere. She said that police enquiries revealed that Thomas Stewart had left Oodnadatta to go to Mintabie about a week before and he was still there with his family when Ferguson returned with Ms Amos’ body. Mr Stewart had a clear alibi. Justice Vanstone said that far from having any remorse for Ms Amos’ death, Ferguson by this conduct attempted to shift the blame elsewhere and followed that up with a plea of not guilty to any offence and upon his trial he remained mute. In short, I cannot do better than adopt Ms Kereru’s summary in her closing address: 'This despicable conduct really epitomises the character of Daniel Ferguson, someone who had no respect for women in life and in Serina's case in death. He treated them with contempt, he used them like objects and refused to be accountable for all his actions.' 2 2 Transcript, page 548

2. Background 2.1. At the time of Ms Amos’ death, Ferguson was the subject of an interstate bench warrant for his arrest. This had been issued by the Northern Territory Supreme Court on 3 June 2015 when Ferguson failed to appear on the third day of a trial which was being held in the Supreme Court sitting at Alice Springs. It appears that Ferguson had, after absconding from the Northern Territory, travelled across the border to Ms Amos’ place of residence in Oodnadatta. Ferguson and Ms Amos had lived together in that residence for most of their approximately 12 month relationship. During that time Ferguson was on bail for the charges the subject of the Northern Territory Supreme Court trial.

2.2. The trial had commenced on 1 June 2015 when Ferguson pleaded not guilty to two counts of sexual intercourse without consent arising from offences alleged to have occurred on 2 and 3 October 2013 against a woman who at the time of the offending was his partner.

2.3. When Ferguson failed to attend on the third day of the trial the presiding judge, Mildren J, ruled that the trial should proceed in his absence. The jury found him guilty of both offences the following day, 4 June 2015.

2.4. The 2013 offences the subject of the Northern Territory Supreme Court trial bear a close similarity to Ferguson’s offending against Ms Amos.

2.5. The charges against Ferguson for the events in 2013 had been dropped when the Northern Territory police lost contact with the victim. As a result Ferguson was released into the community and placed on a bail agreement. When further charges were laid against him when the police regained contact with the victim, Ferguson remained on bail with no conditions. Surprisingly, there was not even a condition that he remain in the Northern Territory or that he be bailed to reside at a particular address.

An address was referred to in the bail agreement, but it was not a condition of his bail that he reside there. As a result of that circumstance Ferguson was free to come and go from the Northern Territory as he pleased, and this he did when he established the relationship with Ms Amos in 2014. From about June of 2014 he spent a considerable amount of time with Ms Amos residing at her residence in Oodnadatta, although they appear to have made frequent trips away from Oodnadatta over the following 12 months.

2.6. It is probable that Ms Amos assisted Ferguson with transport to Alice Springs for his trial in June 2015. It is also probable that Ms Amos was involved in travelling with Ferguson from Alice Springs when he absconded from the trial. It is likely that Ms Amos’ vehicle, a distinctive red van, was used for these travel arrangements.

3. Serina Amos 3.1. Ms Amos was part of a close knit Aboriginal community living in the small town of Oodnadatta. Statements from her family and friends reveal that she was an outgoing and well-liked young woman. She had a daughter who in the months leading up to Ms Amos’ death was living with her father in Port Augusta. A statement of her daughter3 says that before moving to Port Augusta she had lived with her mother Serina until her mother and Ferguson started their relationship.

3.2. As I have said it would appear that relationship commenced when Ms Amos met Ferguson at the Finke Desert Race in mid-2014.

3.3. Ms Amos’ daughter moved out of her mother’s house when Ferguson moved in as she did not like Ferguson. She did not like Ferguson because she had ‘heard a lot of bad stuff about Danny flogging his women in Finke’4. Ms Amos’ daughter also stated that a couple of months after moving to live with her father in Port Augusta she had returned to visit her mother. She said that on that occasion she saw Ferguson pick up a kitchen chair and throw it at her mother, hitting her in the head. Ferguson was drunk. She asked her mother to go to the hospital because she was bleeding from her head, but Ferguson ordered her not to and as a result she did not attend the hospital. It seems that this assault was never reported to the police which is to say the least unfortunate.

3.4. In fact numerous statements that were tendered at this Inquest reveal that a number of Ms Amos’ family and friends were aware, or at least suspected, that she was the subject of domestic violence at the hands of Ferguson. Statements described her as having changed from an outgoing and friendly woman to someone who was withdrawn and would wear sunglasses at odd times when she did go out in public. In particular I refer to the evidence of Kimberly Amos and Darrellyn Hunt, both of whom gave oral evidence in this case. They each described Ms Amos as being an open and friendly person whose behaviour changed almost immediately after she commenced her relationship with Ferguson. Both of them made reference to her habit of wearing 3 Exhibit C35 4 Exhibit C35a

sunglasses and pulling her hair to one side which they thought she was doing to conceal bruises to her face. Reference is made in a number of the witness statements of Ms Amos’ family and friends about their knowledge of Ferguson’s propensity to be violent towards women. References appear to him complaining in a drunken state about his reputation as a man who was violent towards women. I find that his reputation was well known throughout the community and that there was a general understanding that he was likely to be behaving violently towards Ms Amos. The suspicions were reinforced by her unusual habit, never previously displayed, of wearing sunglasses in circumstances where it would not ordinarily be expected. Unfortunately the evidence I have heard reveals that none of these people made reports to the police about their suspicions or observations. Nor for that matter did Ms Amos.

3.5. There was a single instance on 7 July 2014 when Lorraine Jones told Community Constable William Bailes words to the effect ‘Danny is hitting Serina over in Coober Pedy and he is going to smash the car’. Constable Bailes appropriately responded to this information by contacting Coober Pedy police to ask that they investigate. Later that same day Coober Pedy police reported back to Constable Bailes that there was nothing untoward and no concerns had been raised for Serina’s welfare after they had made appropriate enquiries5.

4. The actions of Northern Territory police between 4 June and 18 June 2015 4.1. Detective Senior Constable Easthope of the Northern Territory Police was responsible for investigations to find and apprehend Ferguson. On 4 June 2015 he made numerous enquiries6 however between 5 June and 10 June 2015 Detective Easthope had to undertake some interstate travel. He was unsure who had the responsibility of the investigation in his absence7. He was unsure what had been done to locate Ferguson during this period. There was no other evidence of efforts on the part of Northern Territory Police to find Ferguson during Detective Easthope’s absence. Upon his return on 11 June 2015 Detective Easthope spoke with Donna Tickner who informed him that he should speak to Ferguson’s father. She said that Ferguson’s father would be in Alice Springs on the following day, 12 June 2015. On 12 June 2015 Detective Easthope attended at an address where he expected to find Ferguson’s father, but found no-one home. He did not refer to any other enquiries that he undertook on that day8. He 5 Exhibit C37a, Transcript, pages 462-463 and Exhibit C32a 6 Exhibit C36a 7 Transcript, page 186 8 Exhibit C36a

returned to the same address the following day and was told that Ferguson’s father was in Finke9. It is not apparent that Detective Easthope made any enquiries in Finke.

4.2. Detective Easthope gave evidence at the Inquest and said that he expected that others would have made those enquiries, but he was unable to say what they were10.

4.3. On 18 June 2015 an intelligence alert regarding Ferguson was issued by the Northern Territory Police Cross-Borders DV Intelligence Desk. The intelligence alert11 is headed by the logos of Northern Territory Police, SAPOL and the Western Australian Police and it describes itself as a ‘special crime circular’ in wording along its left margin. The first detail concerning Ferguson is as follows: 'BOLOF: Danny Ferguson' Evidence at the Inquest revealed that the acronym BOLOF is short for be on the lookout for. There follows a photograph of Ferguson together with identifying information including addresses which are simply described as ‘Finke NT and Oodnadatta SA’.

4.4. The document goes on to state: 'On 03 June 2015 NT Supreme Court issues a warrant for FERGUSON’s arrest 2 x Sexual Intercourse without Consent (NT Warrant no. 213439130019).

FERGUSON was found guilty of 2 x Sexual Intercourse Without Consent ex parte.

FERGUSON failed to attend court on the last 2 days of the trial.

FERGUSON violently sexually assaulted his then partner 03 October 2013 at Finke.

FERGUSON usually resides in Finke, NT.

FERGUSON's father has indicated that he may be staying at 56 Spearwood Alice Springs or 164 Amoonguna. NT.

Other information suggests that FERGUSON may be In Oodnadatta, SA.

FERGUSON will NOT be able to be arrested under CBJ.

Ferguson is to be arrested if located in the NT.

Due to Ferguson's location being unknown extradition has not yet been approved. All enquiries made interstate at this stage are for information only.

If located interstate, please contact Detective S/Sgt Malley on (telephone number). ' A copy of the warrant was attached.

9 Exhibit C36a 10 Transcript, page 188 11 Exhibit C65

4.5. The Counsel for the Commissioner of South Australia Police submitted that the opportunity of locating Ferguson would have been greatly enhanced had the intelligence alert been issued much sooner and pointed out that it took the Northern Territory Police 15 days to raise the alert in circumstances where the officer in charge of the Northern Territory CIB at the time, Detective Malley, considered that Ferguson was ‘a high risk for us and we needed him in custody’12.

4.6. Indeed, Detective Malley conceded that it may have been prudent to dispatch the alert at an earlier stage.

4.7. Detective Malley gave evidence that he expected that if Ferguson was discovered by police outside of the Northern Territory, they would make contact with him (Detective Malley) and that would have enabled him to commence arrangements for extradition proceedings. He made it quite clear that he did not expect that Ferguson would be arrested on the Northern Territory warrant before the extradition proceedings were approved for commencement13. This is consistent with the words within the intelligence alert that ‘all enquiries made interstate at this stage are for information only’. That is a rather inelegant way of advising interstate police that they were being provided the intelligence alert for information only and presumably that they should instead follow the direction in the intelligence alert to contact Detective Malley on the stipulated telephone number if they located Ferguson interstate.

4.8. It is useful at this point to make reference to section 82 of the Service and Execution of Process Act 1992 (Commonwealth) which provides that a person named in a warrant issued in a State may be apprehended in another State. By section 5 of that Act the Northern Territory is to be regarded as a State. Thus it was theoretically possible that if Ferguson had been found interstate, for example in South Australia, SAPOL could have arrested him. Nonetheless, the evidence showed that under South Australia Police General Orders members of SAPOL are directed not to arrest under section 82 unless they have written confirmation by the police from the State in which the warrant is issued that extradition proceedings will be pursued by that authority in the South Australian Courts. While at first sight one might have some reservations about this General Order, it probably operates sensibly in most instances. Clearly enough it would be pointless to arrest a person if the issuing State’s police force had for one reason or 12 Transcript, page 197 13 Transcript, page 216

another decided that it would not pursue extradition proceedings. One would assume that a decision not to pursue extradition proceedings would only be made in cases where the person the subject of the warrant was not dangerous and where the circumstances giving rise to the issue of the warrant were not especially serious. Neither of those considerations could be said to apply to Ferguson. Nonetheless, the general rule applied to him. Furthermore, the evidence appeared to support a similar practice being employed in the Northern Territory, and presumably other police forces. Thus SAPOL does not have a different policy from other police forces in this regard. Certainly, it would be assumed by SAPOL and other police forces that in a case such as Ferguson’s, the issuing jurisdiction would be prompt and assiduous in deciding to pursue extradition proceedings against a person such as Ferguson. Certainly on the evidence I received, SAPOL for its part would be prompt and assiduous in advising the Northern Territory that a warrant issued in South Australia in respect of an offender such as Ferguson would be the subject of a prompt extradition application in the Northern Territory if the position were reversed.

4.9. Unfortunately, as this case showed, and as will be apparent later in this finding, the Northern Territory Police were anything but prompt and assiduous in the decision making process whether or not to commence extradition proceedings in South Australia for Ferguson. As I have said, the intelligence alert was issued on 18 June 2015. As will become apparent shortly, Ferguson was positively identified by a member of SAPOL in Oodnadatta on 22 June 2015, and the Northern Territory Police, including Detective Malley, were informed on the same day. Yet it took until 29 June 2015 for the Northern Territory Police to finally make the decision to proceed with an extradition application in South Australia and to advise Brevet Sergeant Sampson accordingly. By then, as the evidence showed and as will become apparent, Ferguson had left Oodnadatta and Ms Amos’ car and Ms Amos had also gone.

4.10. Mr Anderson was the Superintendent Commander of the Far North Local Service Area in 2015 and although he has retired, he gave evidence at the Inquest. He said that if a police officer in South Australia had located Ferguson he expected the officer would make immediate contact with Detective Malley prior to arresting on the interstate

warrant. It was his expectation that the officer would comply with SAPOL’s General Orders14. As I have said, the relevant General Order at the time stated: 'SAPOL will only execute an interstate warrant when requested by interstate police and in circumstances where extradition proceedings are being initiated.' 15 The General Order in relation to extraditions at the relevant time also required a South Australian police officer to await written confirmation that extradition was going to be approved prior to executing a warrant of arrest.

4.11. The obtaining of the approval to extradite by Northern Territory Police was therefore central to Ferguson’s apprehension.

4.12. Detective Malley was aware that the process in existence at the time within the Northern Territory Police was such that it was not unusual to have to wait up to two weeks for approval to extradite an offender from interstate16. This was because of the structure that required support at various levels of the Northern Territory Police up to the Deputy Commissioner or Commissioner before approval would be given to incur the cost of travelling to another State. The process was further complicated by the need to physically transport the extradition file between Alice Springs and Darwin17 which is very difficult to understand in this age of electronic communication.

4.13. The evidence in this matter showed that Superintendent Anderson received the intelligence alert issued by the Northern Territory on 18 June 2015 and he emailed a copy of it to the officer in charge at the Oodnadatta police station, Brevet Sergeant Sampson18. Superintendent Anderson requested Brevet Sergeant Sampson to ascertain if Ferguson was in Oodnadatta. He noted also that extradition had not yet been approved. The alert was also promulgated amongst Coober Pedy police officers.

4.14. Brevet Sergeant Sampson was aware of Ferguson. Earlier in the year he had received information from his counterpart in Finke in the Northern Territory that Ferguson had been charged with some serious offences in the Northern Territory including rape and unlawful imprisonment of a young female.

14 Transcript, page 263 15 Exhibit C58d 16 Transcript, page 204 17 Transcript, page 204 18 Exhibit C68

4.15. Brevet Sergeant Sampson was also aware of Ms Amos. He had spoken to her on a few occasions but he had never seen evidence that suggested she was being assaulted. She never made a complaint about Ferguson.

4.16. After receiving the email about the intelligence alert on 18 June 2015, Brevet Sergeant Sampson checked Ms Amos’ home address to see if there was evidence that Ferguson was in Oodnadatta. Brevet Sergeant Sampson was aware that Ms Amos drove a red van (a Toyota Tarago) which would have been the only means of transport likely available to her or Ferguson. On that day the vehicle was not in the driveway. Brevet Sergeant Sampson then spoke with Ferguson’s brother, Donald Ferguson, to enquire as to Ferguson’s whereabouts. Donald Ferguson said Ferguson and Ms Amos were in Finke19. On 19 June 2015 Brevet Sergeant Sampson sent an email to Superintendent Anderson informing him of the information he had obtained from Donald Ferguson, namely that Ferguson and Ms Amos were thought to be in Finke. He received a response from Superintendent Anderson suggesting that he contact ‘Intel’ should he discover Ferguson in Oodnadatta20.

4.17. On 22 June 2015 Brevet Sergeant Sampson observed Ms Amos’ Toyota Tarago in her property. Later the same day he saw Ferguson in the front yard of Ms Amos’ property but did not approach him21.

4.18. As instructed, Brevet Sergeant Sampson sought advice from ‘Intel’ at Port Augusta.

He could not recall to whom he spoke, but as a result of that communication he then contacted Detective Malley of Northern Territory Police to advise that he had seen Ferguson in Oodnadatta. Brevet Sergeant Sampson advised that if extradition was approved he would be able to arrest. Detective Malley told Brevet Sergeant Sampson that he would speak to his superior and get back to him later that day.

4.19. At 1:57pm on 22 June 2015 Detective Malley sent an email to the Commander of Southern Command in the Northern Territory advising that Ferguson had been located in Oodnadatta and seeking permission to extradite him back to ‘ASP’22 for sentencing.

19 Exhibit C73 20 Exhibit C68 21 Exhibit C73 22 Alice Springs Police

In the email he said that the normal process took a number of days and that Ferguson may ‘run again’. He stated: 'I think we need to move on him very quickly. This one is a bit different as he has been convicted and only needs to be sentenced. He took off on day 3 of his trial. If this isn’t possible I’ll begin the normal application and go through the normal process.' 23

4.20. Immediately thereafter the Commander of Southern Command advised Detective Malley that she supported a quick response and that the paperwork could follow. At 3:06pm that day Detective Malley sent an email to Brevet Sergeant Sampson advising that the request for extradition had been made and he hoped to have approval that day or the next24. Nothing further was heard by Brevet Sergeant Sampson that day.

4.21. In the meantime, in the Northern Territory, Detective Malley realised that the Deputy Commissioner of the Northern Territory Police, Mark Payne, was in Alice Springs and he saw him in a corridor of the building he worked in. He approached Deputy Commissioner Payne in order to seek verbal approval for the extradition. He briefed the Deputy Commissioner in the corridor of the Alice Springs police station, but the Deputy Commissioner requested ‘to see the full file’. He did not give Detective Malley verbal approval to extradite Ferguson25. I did not hear from Deputy Commissioner Payne in these proceedings. He has not had an opportunity to comment on the above version of events as related by Detective Malley. I cannot therefore express criticism of him. At best all I can say is that it is very unfortunate that if a verbal briefing did take place, it did not result in verbal approval being readily and fulsomely granted.

4.22. Detective Malley did not advise Brevet Sergeant Sampson that there would now be a delay26.

4.23. On 23 June 2015 Sergeant Dawson who was the officer in charge of Coober Pedy police was scheduled to be in Oodnadatta to conduct a monthly audit of Brevet Sergeant Sampson’s work. Brevet Sergeant Sampson realised that there would be some advantage to him having the assistance of Sergeant Dawson if the arrest of Ferguson were to occur that day. However, he had not heard anything from the Northern Territory police about that matter. He therefore contacted Detective Malley to seek an update and Detective Malley advised that he would speak with his superior and get back 23 Exhibit C66a and Transcript, pages 203-204 24 Exhibit C66 25 Transcript, pages 205-206 26 Transcript, page 235

to Brevet Sergeant Sampson27. Detective Malley did not mention the fact that he had been requested to submit a complete extradition file which would cause delay. He did not share any concerns he had as consequence of that with Brevet Sergeant Sampson.

He did not contact Brevet Sergeant Sampson again that day. Therefore an opportunity for Brevet Sergeant Sampson to arrest Ferguson that day with the aid of Sergeant Dawson was lost.

4.24. On 24 and 25 June 2015 Brevet Sergeant Sampson said that he continued to monitor Ms Amos’ house. He noted that the red Toyota Tarago van remained in the driveway and although he had not received any information that led him to believe that Ferguson had left town, he did not see Ferguson on either of those days28.

4.25. On 26 June 2015 Detective Malley was asked to submit a second memo to the Deputy Commissioner in support of an application for approval for extradition29. Detective Malley advised that Ferguson had been seen in Oodnadatta: '… a number of days ago, but that local police do not envisage any problems with arresting him and having him returned to Alice Springs for sentencing.' 30 In fact, however, Detective Malley had not contacted Brevet Sergeant Sampson on that day or at any time since 23 June 2015. It is far from clear why it was necessary for a second memorandum to be submitted or what the differences were between the first memorandum and the second memorandum. Again it is unfortunate to say the least that Northern Territory Police could not move more quickly in relation to what on the face of it was a straightforward decision, namely that there could be no dispute that extradition should proceed in respect of Ferguson and that they should inform SAPOL that it would proceed and to arrest him immediately. Why that did not happen remains a mystery.

4.26. On 26 June 2015 Brevet Sergeant Sampson commenced two days of rostered days off.

While on leave he was not required to be on-call. He went to Coober Pedy. He was not intending to return to Oodnadatta until Saturday 27 June 2015 and he was next rostered to work on Sunday 28 June 2015. From the Friday evening until Sunday 27 Exhibit C73 and Transcript, page 235 28 Exhibit C73 29 Exhibit C67 30 Exhibit C67

28 June 2015, Oodnadatta did not have a police officer. Arrangements were however in place for Coober Pedy police to respond to incidents in Oodnadatta31.

4.27. This evidence of Brevet Sergeant Sampson was disputed by Senior Constable White.

Senior Constable White said that his understanding was that Brevet Sergeant Sampson was supposed to be on duty on 27 June 2015 and was on-call that day. It was submitted to me that it was important to resolve this dispute because of the events that unfolded in the early hours of 27 June 2015 which involved, as will presently be seen, the need to recall Senior Constable White and his partner, Senior Constable Waterson, to duty from Coober Pedy to attend disturbances that had occurred at Oodnadatta that night. It was suggested that if instead of Senior Constables White and Waterson attending Oodnadatta on that Saturday morning, Brevet Sergeant Sampson had done so, it would have made a difference to the tragic outcome in this case. The view I have reached is that it is too speculative to draw that conclusion. Accordingly, I do not regard it as necessary to resolve the apparent dispute between Brevet Sergeant Sampson and Senior Constable White on the subject of the rostered day off. As will be seen, Senior Constables White and Waterson duly attended Oodnadatta in response to the disturbances that had occurred. None of the disturbances appeared to involve allegations of criminality against Ferguson. No occasion arose for Ferguson’s arrest.

5. The disturbances in the early hours of 27 June 2015 5.1. At 3:51am on 27 June 2015 a call was received at the police communications centre from an anonymous female caller. The call originated from a payphone at Pink Roadhouse which is on Ikaturka Terrace in Oodnadatta. The female caller was highly emotional and difficult to understand. She was unable or unwilling to provide information as to the reason for her call. Brevet Sergeant Gregory of Port Augusta police station was the night shift supervisor for the Far North Local Service Area when the call was received. She was informed of the call and requested that attempts be made to recall the payphone. She was informed that this was not possible for police communications to do that. She was hesitant to recall officers in the absence of further information32. Senior Constable Robbins was working nightshift at Port Augusta police station with Brevet Sergeant Gregory. At her request he attempted to call a payphone at Pink Roadhouse but was unable to contact the female caller.

31 Exhibit C71c 32 Exhibit C60d

5.2. At 3:59am Senior Constable Robbins received a call from an anonymous caller. The anonymous caller advised that Pamela Dodd was ‘getting a hiding from Anthony Finn at 2 Ikaturka Terrace in Oodnadatta’. Senior Constable Robbins informed Brevet Sergeant Gregory of this call33. At 4:01am Brevet Sergeant Gregory decided to recall Oodnadatta police to duty. After ascertaining that the officer in Oodnadatta was on leave, Brevet Sergeant Gregory decided to recall Coober Pedy police to attend. As a result Senior Constables White and Waterson of Coober Pedy police were recalled to duty at 4:17am and asked to attend Oodnadatta.

5.3. At 4:22am a further call was received at the police communications centre. The caller identified herself as Kristelle Amos. She reported a fight and an argument occurring at 2 Ikaturka Terrace. The origin of the call was identified as 7 Ikaturka Terrace which is the residence belonging to Serina Amos34. There was some evidence to suggest that this caller, although identifying herself as Kristelle Amos, was in fact Serina Amos35.

However, other evidence suggested that at the time of that call Ms Amos was at the home of Kahlia Amos36. I will return to this subject later.

5.4. At 4:57am Senior Constable Robbins received a further call at Port Augusta police station. The caller was female and stated that Ferguson was arguing with the caller’s daughter in the backyard of 2 Ikaturka Terrace. It was subsequently ascertained that the caller was Julie Amos37. Julie Amos is Serina Amos’ aunt and she stated that she saw Ferguson at that time arguing with Kimberly, her daughter. She said that Ferguson appeared to be drunk so she called police38.

5.5. As I have said, despite the evidence suggesting that Serina Amos was the caller to police at 4:22am, at that time other evidence suggests that Ms Amos was not at 247 Ikaturka Terrace while the disputes were occurring. According to Kahlia Amos, Serina Amos had arrived at her house on Kutaya Terrace at 1:30am. She said that she wanted to get away from Ferguson. She told Kahlia that the police were looking for Ferguson. She slept the night at Kahlia’s ‘and got up when the sun came up’. Kahlia told Serina to speak with the police about Ferguson, but she did not want to39.

33 Exhibit C69 34 Exhibit C69a and C71c 35 Transcript, page 69 36 Exhibit C21 37 Exhibit C20 38 Exhibit C20 39 Exhibit C21

6. Senior Constables White and Waterson arrive in Oodnadatta 6.1. Senior Constables White and Waterson arrived in Oodnadatta shortly after 8am. The travel time between Coober Pedy and Oodnadatta was approximately two hours. At 8:05am the two officers attended the address of Anthony Finn and Pamela Dodd and spoke with the occupants of the house. They were advised that Anthony Finn and Pamela Dodd had gone to Pink Roadhouse. They were also informed that they had been asleep all night and that there had been no fight40.

6.2. Shortly after Senior Constables White and Waterson checked the Pink Roadhouse. On arrival they spoke with Anthony Finn and Pamela Dodd separately. These two people were able to corroborate the information that the officers had already received41. The two officers were satisfied that there had not been an incident of domestic violence between Anthony Finn and Pamela Dodd and started to wonder whether the call to police had been a hoax.

6.3. While at Pink Roadhouse the two officers spoke with staff to see whether they had heard or were aware of any disturbances during the night42. They were informed that music had been heard but that it had now ceased43.

6.4. Shortly after this Senior Constables White and Waterson spoke with Anthony Smith who Senior Constable White regarded as a reliable source of information. They asked him whether he had been aware of any disturbances the previous evening but he had not heard anything and was not aware of anything44. Because of the call to police communications regarding a fight on Ikaturka Terrace, the two officers attempted to conduct a welfare check at 247 Ikaturka Terrace. Senior Constable White’s evidence was that he could not gain access45. After that attendance they then proceeded to 242 Ikaturka Terrace and at the rear of that address they encountered an ambulance vehicle on Railway Terrace. Senior Constable White spoke with the occupant who was Pamela Nicholls. Senior Constable White said she reported to him that there had been no issues overnight and no injuries had been treated by her46.

40 Exhibits C79a and C71c 41 Exhibit C71c, Transcript, page 388 42 Transcript, pages 388-389 43 Exhibit C79a, Transcript, page 336 44 Transcript, page 390 45 Transcript, page 543 46 Transcript, page 432, Exhibits C69a and C71c

6.5. Pamela Nicholls is a registered nurse and was working as an agency nurse at Oodnadatta Clinic in 2015. She could not recall speaking with the police, but her evidence was that if she had encountered the police she would have told them of having treated Ms Amos slightly earlier that morning. She would have also told them about concerns she held for Ms Amos’ welfare. I will return to this subject later.

6.6. Senior Constable White was certain that if he had been informed by RN Nicholls that she had treated a wound on Ms Amos only hours earlier and that she harboured concerns that the wound may have been inflicted by a knife and that Ms Amos’ behaviour indicated that she was scared, Senior Constable White is certain that he would have conducted a search for Ms Amos in order to ascertain why she was injured and what had occurred47. I have no hesitation in accepting Senior Constable White’s evidence on that point.

6.7. Having spoken with RN Nicholls, Senior Constable White then entered the property at 242 Ikaturka Terrace and knocked repeatedly on the front and rear doors, but heard nothing in answer so he returned to his vehicle48.

6.8. Between 8:47am and 9:30am Senior Constables White and Waterson drove around speaking to people to ascertain whether there were any further disturbances and whether they could get any further information about anything that had happened overnight49.

6.9. At 9:30am Senior Constables White and Waterson had a meal break at Pink Roadhouse.

Community Constable Bailes recalled running into the two officers while they were in the Roadhouse. He had a brief discussion with them about the jobs in Oodnadatta including those relating to Anthony Finn and Pamela Dodd, as well as the reported argument involving Ferguson.

7. Brevet Sergeant Sampson returns to Oodnadatta 7.1. Brevet Sergeant Sampson returned to Oodnadatta at approximately midday on Saturday 27 June 201550. On his return to Oodnadatta, having seen Senior Constables White and Waterson on the road between Coober Pedy and Oodnadatta, he attended at the police station and undertook a computer search about the events of the preceding night.

47 Transcript, page 433 48 Transcript, page 398 49 Transcript, page 403 50 Transcript, pages 428-429

Following this he checked Ms Amos’ residence but could not see her vehicle. He had a discussion with Donald Ferguson who told him that Ferguson and Ms Amos had left Oodnadatta. He drove around but could find no sign of Ferguson. I find that Ferguson and Ms Amos left Oodnadatta at some time on 27 June 2015.

8. A person jumping a fence 8.1. There was some confusion in the accounts of the officers about whether a report had been received of Ferguson having been seen jumping a fence that morning. In the result I am satisfied that no such information was conveyed at that time. The knowledge that the police officers derived about Ferguson having jumped a fence appears to have come to them in the course of the subsequent investigations concerning Serina Amos’ death.

In brief summary, Darrellyn Hunt recalled seeing Brevet Sergeant Sampson driving his police vehicle on that Saturday. The sighting must therefore have taken place sometime after midday on Saturday, in broad daylight. She was in Pink Roadhouse. At that time she also observed Ferguson jumping the fence of the residences across the road from the Roadhouse. She thought that Ferguson was hiding from the police.

9. Brevet Sergeant Sampson receives confirmation of extradition application 9.1. At 2:22pm on 29 June 2015 Brevet Sergeant Sampson received an email from Detective Malley advising that extradition had been approved and asking that Ferguson be arrested51. Brevet Sergeant Sampson called Detective Malley to advise that Ferguson had left Oodnadatta. Ms Amos’ car had also disappeared.

10. The encounter between police and the nurse 10.1. It will be recalled that Senior Constable White gave evidence that while he and Senior Constable Waterson were driving around Oodnadatta making their enquiries they saw what Senior Constable White described as ‘the ambulance troopy’ driving towards them. They stopped their police vehicle and waited for the ambulance to reach them.

Senior Constable White said that the driver of the vehicle was a nurse, but he could not remember her name. He did recall that she was female and from New Zealand52.

51 Exhibit C68 52 Exhibit C71, paragraph 32

10.2. I heard evidence from RN Pamela Nicholls. She identified an extract from the Oodnadatta Hospital progress notes for Ms Amos53 for 27 June 2015. The note refers to an attendance at 0600 hours that day for Ms Amos. It stated Ms Amos had a lacerated forearm (left) said to have been occasioned by climbing over a fence. It was a full thickness wound, 2cm long. The nurse recorded that it was necessary for her to suture the wound and apply a dressing54. It was clear that RN Nicholls had only the vaguest of recollections about this incident when giving her evidence.

10.3. She said that at about 4am or 5am Ms Amos knocked at her door. She assumed that Ms Amos was aware of her address because the ‘ambulance troopy’ was parked in her driveway. Ms Amos showed her a wound on her left arm which RN Nicholls said was one inch long and was not bleeding at the time. Ms Amos asked if the wound could be stitched and dressed. As it was about 5am RN Nicholls suggested that Ms Amos return at 8am, but Ms Amos wanted the task to be completed then and there. Ms Amos was sober and seemed to be a little bit scared. RN Nicholls said that she did not want to be seen. RN Nicholls drove Ms Amos to the clinic and Ms Amos asked that they not drive down the main street, thus reinforcing the impression that she did not want to be seen.

RN Nicholls said that she asked Ms Amos if she had any concerns and said that Ms Amos could confide in her. Ms Amos would not give any reasons for her desire not to be seen and RN Nicholls did not press her. RN Nicholls did not believe Ms Amos’ account of how she came by the wound, by climbing over a corrugated iron fence. The nature of the wound caused RN Nicholls to think otherwise, but she did not press Ms Amos for further information. She said that the wound required three stitches and that it was a full thickness cut down to the fat. She said that it was only one inch long but it was a surprisingly clean cut.

10.4. RN Nicholls said that she dropped Ms Amos at a house not far from the clinic at approximately 0645 hours that morning after attending to her.

10.5. To this point RN Nicholls’ evidence is entirely consistent with her contemporaneous note in Ms Amos’ medical records. The account makes sense and has the ring of truth about it. However, the balance of RN Nicholls’ evidence stands in stark contrast. She had no recollection of speaking to Senior Constables White and Waterson that morning as described by Senior Constables White and Waterson. There is no doubt that Senior Constables White and Waterson clearly did encounter RN Nicholls. For example, 53 Exhibit C61 54 Exhibit C61

Senior Constable White’s recollection that she came from New Zealand is very pertinent. Furthermore, there were contemporaneous radio transmissions by Senior Constables White and Waterson reporting their encounter with the nurse which were then recorded and have formed part of the records that have been admitted as evidence in this Inquest. There can be no doubt that Senior Constables White and Waterson did indeed encounter RN Nicholls at approximately 8:47 that morning and this is confirmed through the contemporaneous radio communication that was made at that time.

10.6. It was Senior Constable White’s evidence that had he been informed that Ms Amos had been treated by the nurse for an injury he would have most certainly conducted a search for Ms Amos in order to ascertain why she was injured and what had occurred55. It is plain that Senior Constable White was not told any such thing by the nurse he and Senior Constable Waterson encountered that morning. There was only one nurse on duty and in Oodnadatta that day, and the person he encountered must have been RN Nicholls. It beggars belief that any other person purporting to be a nurse would have been driving around in such a small community in an ‘ambulance troopy’ that morning.

10.7. It was RN Nicholls’ evidence that if she had seen police that morning she would certainly have told them about the incident involving Ms Amos given that they had enquired as to whether she had seen any injuries that night. RN Nicholls also said she would have given the police Ms Amos’ name had they made such an enquiry.

10.8. It is impossible to reconcile these two positions. While it did not appear to me that RN Nicholls was attempting to mislead the Court or was deliberately lying, I have no hesitation in accepting the evidence of Senior Constable White, corroborated as it is by the contemporaneous radio communication record. I have been unable to arrive at any explanation for the different account given by RN Nicholls and her inability to remember the encounter. It is difficult to see why she would have concealed her knowledge of Ms Amos’ injury from Senior Constable White that morning. However, the matter must remain a mystery.

10.9. It is deeply regrettable that RN Nicholls did not manage to transfer her knowledge of what had happened to Ms Amos that morning to Senior Constables White and Waterson. There is no doubt that had she done so, the officers would have made every 55 Transcript, page 433

effort to find Ms Amos. In all probability they would have prevented Ms Amos from leaving town that day with Ferguson. That in turn would have prevented her death.

11. Changes to General Orders 11.1. I was informed by counsel for the Commissioner of Police that while the process of executing interstate warrants has worked well in the past between SAPOL and bordering States, SAPOL has nevertheless seen some benefit in amending the relevant General Orders to remove the necessity for its officers to have to rely on police of another State or Territory before acting. The changes will ensure that the arrest of interstate offenders will be expedited where necessary should the circumstances so warrant. The General Order ‘Warrant Procedures’ was amended in September 2018.

It is not necessary for me to quote the relevant provisions in this finding. Furthermore the General Order ‘Extraditions’ was amended at the same time. It is commendable that SAPOL has taken these steps and I hope that they would prevent a repetition of such a tragedy as Ms Amos’ death at the hands of Ferguson in future. However, it is plain that the central problem in this case was the extraordinary delay in the Northern Territory Police obtaining approval for Ferguson’s extradition and then advising SAPOL once the approval had been obtained. I heard evidence from one of the Northern Territory Police officers that they have now changed their procedures in relation to extradition to ensure that if this situation were to occur again, extradition would be able to be approved on the same day it is requested56. It is deeply regrettable that Northern Territory Police did not respond promptly and efficiently in 2015 in this case.

11.2. I have no recommendations to make in this matter.

Key Words: Homicide; Interstate Extradition Delays In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 27th day of March, 2019.

State Coroner Inquest Number 19/2018 (1158/2015) 56 Transcript, pages 223-224