Coroner's Finding: ROBERTS Paul 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 10th day of October 2019 and the 7th day of December 2020 by the Coroner’s Court of the said State, constituted of David Richard Latimer Whittle, State Coroner, into the death of Paul Scott Roberts.

The said Court finds that Paul Scott Roberts aged 38 years, late of 32 Morley Road, Seaton, South Australia died at Seaton, South Australia on the 7th day of September 2015 as a result of combined effects of incineration and inhalation of products of combustion. The said Court finds that the circumstances of his death were as follows:

1. Introduction and reason for inquest 1.1. Paul Scott Roberts, aged 38, died on 7 September 2015, after setting fire to himself when police attended to arrest him at his home in Seaton. At the time of his death he was being detained under home detention intensive bail supervision pursuant to the Bail Act 1985. Mr Roberts entered into that bail agreement on 31 July 2015 at the Port Adelaide Magistrates Court.

1.2. Mr Roberts’ death was a death in custody as defined in the Coroners Act 2003, in respect of which an inquest was mandatory, for two reasons: firstly, Mr Roberts was being detained pursuant to home detention bail; secondly, he was in the process of being apprehended by the police officers who attended his house to arrest him for an alleged breach of an intervention order and other offences.

1.3. These are the findings of the mandatory inquest into Mr Roberts’ death.

2. Cause of death 2.1. A post-mortem examination on the body of Mr Roberts was conducted at Forensic Science South Australia by forensic pathologist Dr Karen Heath on 8 September 2015.

Dr Heath concluded that the cause of death was the combined effects of inhalation of products of combustion and incineration.1

2.2. There were third degree burns with charring involving greater than 90% of the total body surface area. Dr Heath notes in her report that generally it is accepted that burns involving 30-50% of the total body surface area are incompatible with survival.

2.3. The blood alcohol concentration was 0.129% and the urine alcohol concentration was 0.168%. No other drugs were detected in the blood.2

2.4. No natural disease that could have caused or contributed to the death was identified at autopsy.

2.5. I accept the conclusion of Dr Heath and find that Mr Roberts died as a result of the combined effects of inhalation of products of combustion and incineration.

3. Background 3.1. Mr Roberts was born on 13 January 1977 and was the only son of Alan and Lynette Roberts.3

3.2. Mr Roberts suffered from a serious eye condition, bilateral corneal dystrophy and was declared legally blind in 2010. He suffered from chronic dysthymia, a persistent depressive disorder, which was complicated by regular binge drinking and problem gambling. Mr Roberts was supported in the community by a supportive family, psychologist and general practitioner. He was medicated but had a history of poor coping with stressors, leading to alcohol abuse, further promoting a depressive mood state. Mr Roberts had a long history of engaging in self-harming behaviour as well as threatening and attempting suicide, particularly following relationship breakdowns.

3.3. Despite these difficulties Mr Roberts maintained ongoing employment and at the time of his death had been employed by a boat dealer, as a general handyman, since October

2014. He was a reliable, conscientious employee.

1 Exhibit C1a 2 Exhibit C2a 3 Exhibits C7 and C8

3.4. At the time of his death Mr Roberts was engaged to, but recently separated from, Ms Donna Falls. Ms Falls’ youngest child Sophie, 14 months of age, was the biological daughter of Mr Roberts.4

3.5. On 13 December 2014, police were called to attend the home that Mr Roberts shared with Ms Falls in West Lakes. Mr Roberts was arrested and detained pursuant to section 57 of the Mental Health Act 2009 due to his behaviour and threats to damage property. He was intoxicated at the time of his arrest.

3.6. Mr Roberts was released from hospital later that day but at about 1am on 14 December 2014 police reattended the home shared by Mr Roberts and Ms Falls. There had been an argument between them. Mr Roberts had poured petrol over himself and threatened to set himself alight if police were called. When police attended, Mr Roberts attempted to ignite a cigarette lighter. Police used a garden hose and fire extinguisher to immediately douse the flame. After being detained by police under the Mental Health Act, Mr Roberts continued to threaten to kill himself and to come back to kill Ms Falls.

He was taken to the Queen Elizabeth Hospital and served with an interim intervention order protecting Ms Falls and her children and prohibiting contact between Mr Roberts and any of them.

3.7. Mr Roberts remained in hospital until deemed fit to be released on 16 December 2014, upon which he was arrested and subsequently placed on remand at Yatala Labour Prison on 17 December 2014. On 19 December 2014, the intervention order was continued by the Port Adelaide Magistrates Court.

3.8. Mr Roberts remained in custody until 8 January 2015, when he appeared before the Port Adelaide Magistrates Court and was convicted of an offence of aggravated assault, relating to the incident on 14 December 2014. He was released on a good behaviour bond for 18 months, with supervision from 8 January 2015 until 7 July 2016.

Mr Roberts was initially to live with his parents in Marion but soon afterwards moved to an address in Seaton. Ms Falls had by then moved to a new house, the location of which was unknown to Mr Roberts but was approximately 600 metres away from where he was living.

3.9. On 19 January 2015, Ms Falls requested and later secured a variation to Mr Roberts’ intervention order, to allow contact by telephone between Mr Roberts and the children.

4 Exhibit C5

3.10. On 12 July 2015, Mr Roberts’ mother visited him at his home in Seaton. She understood there had been an argument between Mr Roberts and Ms Falls. She found Mr Roberts in the back yard, where there was a rope that he had been tying into a noose.

She said he was very angry and yelling. This incident was not reported to police and only came to light after Mr Roberts’ death.

3.11. On 26 July 2015, Mr Roberts was arrested by police after making many telephone calls to Ms Falls late on 25 July 2015. Two of the telephone calls were recorded and included Mr Roberts stating to Ms Falls that he wanted to die, telling her to call the police and that he ‘would go down fighting’. He told Ms Falls that he was coming to her house.

When Ms Falls told him that she had children at the house, Mr Roberts said, ‘I don’t give a shit’. He also told Ms Falls: ‘So, I’m coming round to your place now with a can of petrol. You call the police, hey.

And we’ll have it out. And, I want to fucking be standing at the front door and I want you to see what happens.’ 5

3.12. STAR Group police attended and Mr Roberts surrendered after about an hour of negotiations. He was arrested and taken to the Queen Elizabeth Hospital for a mental health assessment. He was affected by alcohol. Following assessment, he was considered fit for police custody and was charged with offences of contravening the term of an intervention order, threatening to kill or endanger life, creating a false belief that an offence had been committed and using a carriage service in a harassing or offensive manner.

3.13. Mr Roberts was detained on remand at Yatala Labour Prison from 27 to 31 July 2015 for this alleged offending and then placed on home detention bail. Mr Roberts remained on home detention bail until his death.

4. 6 and 7 September 2015 4.1. Ms Falls had two or three missed calls from Mr Roberts during the evening of 6 September 2015 and the early hours of 7 September of 2015. She subsequently answered one of the calls and said, 'Why are you calling me? You aren't supposed to call me'. Mr Roberts said, 'I don't care'. Ms Falls describes Mr Roberts as rambling 5 Exhibit C78au

and with slurred speech, although he denied drinking. He repeatedly asked Ms Falls to attend his house, which she refused. He then hung up the telephone.6

4.2. Mr Roberts then repeatedly called Ms Falls' mobile telephone so she called Mr Roberts' father, Allan Roberts, who called his son to try calm him but was unable to do so.

Mr Roberts told his father, 'No way I'm going back to fucking gaol, I'm out of here'. He also threatened to go to Ms Falls' house with a nail gun, douse himself in petrol, and set fire to himself on the doorstep.7 Allan Roberts telephoned Ms Falls and told her, 'Paul just said if you do not answer the phone in the next 10 minutes he's coming around to your house to do damage'.8

4.3. Police were advised when Ms Falls telephoned 000 at 1:22am. The call was 9 minutes and 25 seconds long. Ms Falls told the Police Communications Centre operator that she had children in the house, that Mr Roberts was on home detention bail, and had an intervention order prohibiting contact. She told the operator that Mr Roberts had left a message saying that, '…he's going to take his own life and it's my fault'. She said 'It's on my call log. I must have 50 missed calls from him but I believe that he just told his father that if I do not answer the phone within the next, you know, five or ten minutes that he’s gonna come to my house’.9 Police called the Department for Correctional Services monitoring centre at approximately 1:30am to ascertain whether Mr Roberts was inside his address, as he was subject to electronic monitoring. The centre confirmed that he was at his home address.

4.4. At about 1:43am a police patrol arrived at Ms Falls’ address, and shortly afterwards her telephone began ringing again. The police were Probationary Constable Bothma and Constable Engelbrecht. Ms Falls told them of the intervention order, and that it was Paul Roberts calling her. Constable Engelbrecht answered the call and told Mr Roberts that there was an intervention order and that they would be coming to see him. Ms Falls recalls telling the officers that she thought that Mr Roberts would either abscond or hurt himself: ‘He will be one of two things, he will either make a run for it or he will hurt himself’. Constable Engelbrecht recalls Ms Falls telling him that Mr Roberts, ‘…does stupid things when he’s drunk’ and that ‘in the past he threatened self-harm but that was only when he was drunk’.10 They then discussed that he did not sound drunk on 6 Exhibit C5 7 Exhibit C8 8 Exhibit C5 9 Exhibit C78ag 10 Exhibit C78aa

the telephone. The police officers began to take a statement, and photographed details from Ms Falls' mobile telephone until another patrol attended. Ms Falls asked not to be left alone, and so Probationary Constable Bothma and Constable Engelbrecht left, whilst the other officers remained with Ms Falls. There was still reason to fear that Mr Roberts would come to her house. Two voicemail messages were left by Mr Roberts on Ms Falls' telephone. One of those messages was pleading with Ms Falls to attend his house, and the second was blaming her for what he was about to do.

4.5. Probationary Constable Bothma and Constable Engelbrecht left Ms Falls’ address soon after 2am and travelled to Mr Roberts’ house, which was approximately 600 metres away. On their arrival at 2:08am the lights in the house were off. They knocked, with no answer and tried the doors, which were locked. They looked into the lounge room window and could not see anybody. At first, they thought Mr Roberts was not there and that perhaps he had gone to Ms Falls’ house. Then they were informed that the deceased’s home detention bracelet was on the premises. After knocking again on the door and identifying themselves as police, they called Mr Roberts’ mobile phone and heard it ringing inside, so they lifted the security roller shutter on a front window, sufficiently to see inside, where Mr Roberts was lying on a bed. Immediately, at 2:22:26am, they advised over the police radio that they required urgent assistance as they could see a male person on a bed with a can of petrol on top of him, and a lighter in his right hand. Police tried to speak to Mr Roberts and call his name, but he said nothing and only looked in their direction. At 2:22:49am they advised that Mr Roberts started to pour petrol on himself and that they were trying to break into the house. At 2:23:06am they advised that Mr Roberts had set himself alight, and police called for the Metropolitan Fire Service. At 2:23:43am an ambulance was requested. By 2:24:52am the house was described as 'well alight'.11 Probationary Constable Bothma and Constable Engelbrecht attempted desperately to enter the house. They were able to break the window and empty their fire extinguisher in a vain attempt to put out the fire and save Mr Roberts’ life.12 Both officers were later treated for smoke inhalation.

4.6. The scene was examined by fire examiner Andrew Bartlett, who located Mr Roberts’ body at the southern end of the bed facing upwards.13 Underneath him was a large kitchen knife. Two cigarette lighters were located. A sample of liquid taken from the remnants of a plastic container located on the floor of the bedroom was later identified 11 Exhibit C78a 12 Exhibits C78z and C78aa 13 Exhibit C63

as petrol. Mr Roberts had used petrol from a 23-litre plastic container, which was in a boat stored at his house that he was buying from his employer, George Bell.

5. Information given to the attending police officers 5.1. The information that Mr Roberts had threatened to take his own life was not passed on to officers Engelbrecht and Bothma by the Communications Centre operator. I note, however, that the attending patrols were provided with the information directly from Ms Falls on their arrival at her house, that Mr Roberts may self-harm. They then spoke with Mr Roberts on the telephone. When they attended at his address, they were aware that Mr Roberts was threatening to self-harm.

5.2. The information provided by Ms Falls to the Communications Centre Operator that, '…he's going to take his own life…’ should have been communicated to the attending patrol officers. It was relevant information that would have been significant in informing the decision faced by the patrol officers as to how they were to approach Mr Roberts.

6. SAPOL amendments to Communications Centre procedures 6.1. I was advised during the inquest, and I accept, that an updated SAPOL Communications Group Local Policy, ‘Managing Calls for Assistance’, was implemented as a result of this incident. The most recent version of the document has a date of operation of 1 July

7. It states: ‘It is critical all information received which may impact or assist a patrol in their appraisal of the event is entered onto the relevant SACAD event. The assessment of this information by the call taker will assist in the timely response to requests for police assistance and contribute to work, health and safety of operational police and the safe management of police operations.’

8. The supervision of Mr Roberts by the Department for Correctional Services 7.1. Mr Roberts' mother, Lynette Roberts, in her first statement, raises a concern as to whether Mr Roberts was ‘receiving help’ whilst under supervision, in accordance with the conditions of his good behaviour bond.14

7.2. The bond, signed on 8 January 2015, included conditions to attend programs, as directed by his supervising Department for Corrections officer, especially as they relate 14 Exhibit C7

to drug and alcohol abuse, and anger management, and to undertake such medical, psychological, psychiatric assessments and treatments as directed by his supervising Department for Corrections officer.

7.3. Mr Roberts' bond supervision was initially undertaken by the Edwardstown Correctional Centre. On 3 February 2015, Mr Roberts advised his case manager that he had moved to a new rental property at Seaton, so on 5 February 2015 his supervision was transferred to the Port Adelaide Community Correctional Centre. Ms Lidia Barbera assumed responsibility for his supervision. Mr Roberts attended for supervision on a total of 17 occasions before his death.

7.4. Ms Barbera states that upon commencement of supervision, a risk of re-offending screening tool and offender needs analysis tool were administered. Mr Roberts was identified as a low level of risk, and low level of need, with treatment required in the areas of domestic/familial relationships and alcohol use, as well as mental health issues and anger management. His supervision was conducted fortnightly. Given the nature of the offending which led to the bond, counselling to address his domestic violence and anger management issues were considered his primary treatment needs.15

7.5. On 23 March 2015, Ms Barbera organised an appointment for Mr Roberts with a counsellor, Mr David Akbar from Uniting Care Wesley, for domestic violence and anger management counselling. She recalls that Mr Akbar confirmed with her the following day that he had the capacity to work with Mr Roberts, and Mr Roberts was encouraged to make an appointment. Ms Barbera states that she followed up on the referral on 31 March 2015 by having Mr Roberts sign forms allowing contact between DCS and Uniting Care Wesley regarding Mr Roberts' treatment and emailing Mr Akbar an authority to release information. Ms Barbera then met with Mr Roberts on 13 April 2015 and he advised her that he had made attempts to contact Mr Akbar, but had not yet received a response. On 4 May 2015, when Mr Roberts reported for supervision, he advised that he had not heard anything further from Mr Akbar regarding an appointment. To this, Ms Barbera states that she followed up by sending Mr Akbar an email. Ms Barbera was then on six weeks leave, during which Mr Roberts reported fortnightly, as required, to the duty supervising officer.

7.6. On 29 June 2015 Mr Roberts attended his supervision appointment, and advised Ms Barbera that his relationship with Ms Falls had improved, and they had arranged 15 Exhibit C14

counselling through Relationships Australia. However, on 26 July 2015, as previously described, Mr Roberts was arrested and was kept in custody until 31 July 2015 when he was released on home detention bail.

7.7. Throughout August of 2015, Ms Barbera attempted, unsuccessfully, to contact Mr Roberts, leaving voicemails and sending letters. Due to his recent alleged reoffending, his return to custody and his failure to resume reporting, following his release on home detention bail, a decision was made to increase Mr Roberts’ good behaviour bond supervision from fortnightly to weekly face-to-face appointments.

7.8. On 24 August of 2015 when he attended for supervision as requested, Ms Barbera states that Mr Roberts told her – genuinely, she thought – that he was not aware that he was required to report whilst subject to home detention bail. Ms Barbera discussed with Mr Roberts various issues including obtaining a general practitioner mental health care plan to obtain psychological counselling, and relationship counselling with Relationships Australia. Mr Roberts told her he had stopped drinking after work, was eating and sleeping well and was being visited regularly by his parents while on home detention. These she regarded as positive indications. However, Mr Roberts voiced frustration at not being able to see his daughter and, in that context, mentioned that some men commit suicide. He strongly denied any intention to do so himself.

Appropriately, given Mr Roberts’ comments, Ms Barbera spent an extended period – about an hour – with him discussing these various thoughts and issues.

7.9. Mr Roberts' last supervision appointment was on 31 August 2015, with the team supervisor because Ms Barbera was unwell. The supervisor was aware of the issues raised on the previous occasion because Ms Barbera had told him. Mr Roberts advised that he had an appointment to see his general practitioner later that day for some health issues and to discuss counselling options, and an appointment with his lawyer on 2 September 2015. There was nothing to indicate what was to come.

7.10. In relation to failing to engage with counsellor Mr Akbar, Ms Barbera states that Mr Roberts was not in breach of any of the conditions of his bond as he had not failed to comply. He had expressed a willingness to attend and advised his supervising officer of those attempts. He appeared to be actively engaging with a general practitioner and taking appropriate steps to obtain counselling services.

7.11. Mr Akbar has provided an affidavit.16 He states that he has no memory of Mr Roberts and there is no record to indicate that Paul Roberts made contact or received support from Uniting Care Wesley. However, he could not say whether there had been records, as it was organisational practice at the time to not keep records after six months, for clients who did not engage with the service.

7.12. I cannot now determine the circumstances and extent of Mr Roberts efforts to establish contact with Mr Akbar with a view to commencing therapy; nor can I determine whether, contrary to what he told Ms Barbera, his efforts to do so were half-hearted.

7.13. I conclude that there is no basis to criticise the nature or extent of supervision of Mr Roberts by the Department for Correctional Services. Mr Roberts was attending his appointments with Ms Barbera regularly, and there were plausible explanations for his failures to attend. I find that his supervisors’ efforts to engage him with therapeutic services were appropriate, and Mr Roberts gave the impression that he was responding to those efforts.

8. Was Mr Roberts’ death preventable?

8.1. I find that the failure to inform the attending police that Mr Roberts had threatened to take his own life did not contribute to Mr Roberts’ death. The patrol officers were aware that Mr Roberts had previously made threats to self-harm or might hurt himself.

They attended Mr Roberts’ house intending to arrest him for breaching the intervention order. It was appropriate for them to go to his house immediately, given his threats to attend Ms Falls’ house, which they had to ensure he did not do, and the risk, of which they were aware, that he might harm himself. When they got there, what they did to determine whether he was in the house was appropriate. I cannot speculate what might have occurred if they had withdrawn rather than lifting the roller shutter. I do conclude that it was not inappropriate for them to do so.

8.2. Although this issue was not developed at the inquest, I observe that it might be questioned whether police attendance to arrest Mr Roberts should have been declared high risk, which would have initiated the attendance of STAR Group police, with negotiators if available. However, having regard to what occurred, I cannot conclude that the outcome would be likely to have been different.

16 Exhibit C93

8.3. I am satisfied, having regard to the telephone calls made to Ms Falls, and to what Mr Roberts later did, that he was expecting police to attend to arrest him and he intended to end his life rather than be taken into custody. After preparing with petrol and lighter, he doused and lit himself, without delay, once he could see the police and knew they could see him. He made sure that he did so before police had any opportunity to get close enough to save him. The police officers cannot be criticised for being unable to break in quickly enough to save Mr Roberts from setting himself alight. They did everything they could. There is no reason to think that the outcome would have been different if the attending patrol officers were aware of the additional information that Mr Roberts had threatened to take his own life.

9. Investigation report 9.1. I have been greatly assisted in my assessment of this matter by a thorough and detailed investigation and report by Detective Sergeant Brian Mitchell of the Major Crime Investigation Branch.

9.2. He recommended there be a review of the SAPOL Communications Centre process relating to Ms Falls’ 000 call. I am satisfied that this has been attended to and appropriately acted upon, as mentioned in section 6 above.

10. Recommendations 10.1. I make no recommendations.

Key Words: Death in Custody; Suicide; Police Presence In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 7th day of December, 2020.

State Coroner Inquest Number 25/2019 (1599/2015)