Coroner's Finding: Bombardieri, Mark

CORONERS COURT OF SOUTH AUSTRALIA DISCLAIMER - Every effort has been made to comply with suppression orders or statutory provisions prohibiting publication that may apply to this judgment. The onus remains on any person using material in the judgment to ensure that the intended use of that material does not breach any such order or provision. Further enquiries may be directed to the Registry of the Court in which it was generated.

INQUEST INTO THE DEATH OF MARK BOMBARDIERI [2025] SACC 2 Inquest Findings of his Honour Deputy State Coroner White 7 March 2025

CORONIAL INQUEST Examination of the cause and circumstances of the death of Mark Bombardieri, a 32-year-old man who died by suicide with a firearm. The inquest examined the circumstances of how he acquired the firearm from his grandfather’s property and the response of SA Police once it was discovered the firearm was missing.

Held:

1. Mark Bombardieri, aged 32 years of Beverley, died at Beverley on 6 March 2019 as a result of gunshot wound to the head.

2. Circumstances of death as set out in these findings.

No recommendations made.

Counsel Assisting: MR P LONGSON Interested Party: COMMISSIONER OF POLICE Counsel: MR M ROBERTS - Solicitor: CROWN SOLICITOR’S OFFICE Witness: SERGEANT S POPE Counsel: MS H ROGERS - Solicitor: TINDALL GASK BENTLEY Witness: DETECTIVE SERGEANT K FORREST Counsel: MR C KUMMEROW - Solicitor: OLIVIA FANTIS LEGAL Hearing Date/s: 02/05/2023-04/05/2023, 18/05/2023 Inquest No: 4/2023 File No/s: 0474/2019

11 12 13 14 15 16 This judgment contains discussion of suicide and may be distressing to some people There is always help available If you need support, contact Lifeline Australia Call 13 11 14 or Text 0477 13 11 14 or chat online at www.lifeline.org.au/crisis-chat Aboriginal & Torres Strait Islander Support Call 13YARN (13 92 76) Kids Helpline Call 1800 55 1800 MensLine Australia Call 1300 78 99 78

INQUEST INTO THE DEATH OF MARK BOMBARDIERI [2025] SACC 2 Introduction At 10:20pm on Wednesday 6 March 2019, SA Police1 entered a room rented by Mark Bombardieri, at 47 Golding Road, Beverley.2 Mr Bombardieri was found deceased, with a bullet entrance wound in his right temporal region and a .22 rifle resting on his chest.3 The bullet wound was self-inflicted. The rifle was stolen by him from his grandfather’s shed.

Mr Bombardieri was 32 years of age. He was the second son of Carmelo and Maria Bombardieri and the loved grandson of Alfredo and Giuseppina Dimasi, who resided at 1488 Port Wakefield Road, Waterloo Corner.4 Mr Bombardieri had fathered a son in 2014 who tragically passed away at the age of seven weeks. In 2018 his daughter was born. At the time of his death, he was not employed.

Cause of death On 12 March 2019 Dr Cheryl Charlwood, a forensic pathologist at Forensic Science South Australia,5 performed a post-mortem examination of Mr Bombardieri.

Dr Charlwood made the following observations about the fatal head wound, namely that: ‘a gunshot entry wound that appeared at close range was confirmed to the right temporal region of the scalp. The entry wound was a circular to slightly irregular (0.4 x 0.5cm) defect with some sooting to the interior aspect and faint surrounding bruising. The gunshot missile track had penetrated the skull and showed associated right frontotemporal parietal scalp bruising. The gunshot track appeared to traverse the under surface of both frontal lobes of the brain, with associated copious subarachnoid haemorrhage and subdural haemorrhage.’ 6 She noted Mr Bombardieri had aspirated blood, with blood-stained fluid emanating from the mouth and nose, and throughout the airways. His lungs demonstrated prominent pulmonary oedema.

His skull demonstrated significant comminuted fractures, including the skull base in all three cranial fossae. A deformed projectile was located in the left frontotemporal region.

There was no exit wound.

Dr Charlwood did not identify any significant natural disease that contributed to Mr Bombardieri's death. Dr Charlwood determined the cause of death to be a ‘gunshot

1 SAPOL 2 Exhibit C40 at [21]; 47 Golding Road 3 Exhibit C41 at [18]-[20] 4 1488

5 FSSA 6 Exhibit C1a, page 2

[2025] SACC 2 Deputy State Coroner White wound to the head’.7 I accept her opinion and make a finding about his cause of death accordingly.

Mr Bombardieri’s blood was sampled at post-mortem for toxicological analysis by FSSA.

The analysis showed the presence of methamphetamine and buprenorphine and their respective metabolites. Neither drug was found in toxic concentrations.8 The position of Mr Bombardieri and the firearm Constable Gregory Norman was the first SAPOL officer to enter Mr Bombardieri’s room.9 The room was in darkness, but Constable Norman could make out by the light behind him, a person laying on the bed with a firearm against their chest and between their arms. He immediately removed the firearm and laid it on the floor adjacent to the bed.10 In the early hours of 7 March 2019 SAPOL Crime Scene Examiner Brevet Sergeant Plummer attended at 47 Golding Road. He examined the firearm. It was a Fabrique Nationale pump action rifle, serial number 97670.11 He took the following measurements: Overall length - 993mm • Barrel length - 559mm • • Distance from muzzle to trigger - 639mm12 Dr Charlwood made the following measurements of Mr Bombardieri at the post-mortem examination: Body length - 169cm • Arm span - 167cm • Right shoulder tip to index fingertip - 71cm • • Right axilla to right index fingertip - 67cm13 Based on these measurements it was concluded that Mr Bombardieri was capable of holding the muzzle of the Fabrique rifle at essentially a 90-degree angle to the right temple with his left hand and operating the trigger with his right hand.

There are no eyewitnesses to the shooting, but the evidence suggested that Mr Bombardieri was sitting up when the gunshot was inflicted. It would have caused an instant loss of consciousness, and he would have fallen back on the bed. As he fell 7 Exhibit C1a 8 Exhibit C2a 9 Exhibit C65 10 Exhibits C41 and C62a 11 The Fabrique rifle 12 Exhibit C62 13 Exhibit C1a

[2025] SACC 2 Deputy State Coroner White backwards the Fabrique rifle, which Mr Bombardieri still had both his hands upon, has fallen onto his chest. This was also as his upper body fell backwards and his arms have fallen downwards, unconsciously still controlling the Fabrique rifle.14 The Fabrique rifle was submitted to the SAPOL Fingerprint Bureau, but no suitable fingerprints were located for any comparison to be undertaken.15 Swabs were taken from the front and back of Mr Bombardieri's hands by Brevet Sergeant Plummer whilst at 47 Golding Road. Examination by FSSA of each of those swabs showed ‘particles highly characteristic and indicative of GSR’ (gunshot residue).16 On the basis of the evidence, I am comfortably satisfied that Mr Bombardieri: Was capable of operating the Fabrique rifle to discharge the fatal shot; • Did deliberately use the Fabrique rifle in bedroom 3 of 47 Golding Road, to inflict • the gunshot wound to his right temple; Died by suicide.

• Mark Bombardieri - background Mr Bombardieri was born on the 2 December 1986. He was the second of three sons born to Carmelo and Maria Bombardieri.17 Mr Bombardieri was educated mainly within the Catholic school system to Year 9 level. He then undertook a variety of jobs, including working with his father in the real estate industry. He moved to Queensland when he was 19 years of age.18 As a youth, he became involved in criminal activity. He had a number of appearances in the Youth Court, principally for driving and associated offences. He also committed a serious criminal trespass and a common assault. Both these crimes were dealt with by way of not recording a conviction. Two further appearances in the Magistrates Court as a young adult followed for very minor matters.19 In 2007, whilst driving through NSW, he was involved in a high-speed chase with police that resulted in the death of a member of the public. Mr Bombardieri pleaded guilty to aggravated dangerous driving causing death. Following a successful appeal against sentence, Mr Bombardieri was sentenced to an immediate period of imprisonment of 9 years with a non-parole period of 5 years and 9 months, backdated to 12 August 2007.20 14 As communicated by Dr Charlwood 15 Exhibit C62 16 Exhibit C3a 17 Exhibit C10 18 Exhibit C17 19 Exhibit C63q 20 Bombardieri v R [2010] NSWCCA 161

[2025] SACC 2 Deputy State Coroner White Mr Bombardieri was 20 years of age when he was taken into custody. He was released in 2013, aged 26 years. He was reincarcerated at least once for breaching the terms of his parole.21 Mr Bombardieri was further incarcerated in 2017 for an offence of property damage.22 Medical history Mr Bombardieri attended the South Road Day Night Surgery. Apart from his period of incarceration interstate, Mr Bombardieri attended this practice throughout his life, primarily seeing Dr Marko Zuvela, following his release from custody.23 The records of South Road Day Night Surgery demonstrate that Mr Bombardieri was originally prescribed antidepressants, anxiolytics, sleeping medication and opioid pain relievers in 2003, when he was aged only 17 years. Mr Bombardieri remained on these types of medications until his death. Mr Bombardieri had a history of antisocial personality disorder, major depression, anxiety and childhood ADHD/Autism spectrum disorder.24 Mental health history Mr Bombardieri spent time in confinement at mental health facilities. A separation summary from Glenside Hospital in 2017 makes reference to a ‘high lethality suicide attempt in 2007 by carbon monoxide poisoning’.25 Since Mr Bombardieri was released from custody in NSW in 2013, he had seven admissions to public hospitals for psychiatric health conditions. In July 2016 he presented with his mother to the Queen Elizabeth Hospital26 with worsening suicidal ideation. In November 2016 Mr Bombardieri was admitted to Glenside for drug induced psychotic disorder and expressing suicidal ideation. In August 2018 he was admitted to the Cramond Clinic at the QEH with drug induced psychosis and severe depression.27 In 2018, Mr Bombardieri was admitted to the Royal Adelaide Hospital28 following a report of attempted carbon monoxide poisoning in the context of methamphetamine use.29 Within days of being discharged by the RAH he was detained by SAPOL following a report by his ex-partner that he was expressing suicidal ideation. In September 2018 he was admitted to the QEH with ‘affect dysregulation and suicidal ideation in the context of anticipatory anxiety of the birth of his daughter in the coming weeks’.30 21 Transcript, page 161 22 Exhibit C63q 23 Exhibits C18 and C69 24 Exhibit C18 25 Exhibit C69

26 QEH 27 Exhibit C69

28 RAH 29 Exhibit C69 30 Exhibit C69, page 64

[2025] SACC 2 Deputy State Coroner White The medical records demonstrated that Mr Bombardieri had a long history of polysubstance abuse dating back before his incarceration in NSW.

Within the records of the South Road Day Night Surgery was a letter dated 5 January 2017 from Yarrow Place to Dr Zuvela. The letter refers to a sexual assault reported by Mr Bombardieri that occurred on 23-24 December 2016.31 Friday 1 March 2019 On Friday 1 March 2019 Mr Bombardieri attended the Findon branch of the Commonwealth Bank of Australia,32 on four separate occasions. On the first occasion he became frustrated with the teller who wanted to see some photo identification as he said he did not have his CBA card with him. She had insisted on production of the CBA card before she would disclose the balance of his accounts.33 Mr Bombardieri said that he was expecting a large deposit from overseas and became ‘angry’ when the deposit was not present. The teller noted that each account was either in debit or had no balance. Mr Bombardieri then left the bank.

He returned a short time later and a different staff member attended on Mr Bombardieri, who advised him that there was no money within any of his accounts. He asked for a complaint form and ultimately left the bank. A short time later, he returned and dropped an envelope into the quick cash slot.34 Inside the envelope was the complaint form, which expressed his feelings about being alone, being sick and wanting to be with his loved ones.35 The complaint form did not address any issue that Mr Bombardieri may have had with the CBA.

The manager received a call from the CBA customer service centre, advising that they had a customer on the line who wanted to speak to the initial teller who had served Mr Bombardieri. The manager did not allow that call to be put through. Shortly thereafter, Mr Bombardieri reappeared in the branch, claiming that he was being stalked on Facebook by the original teller who had served him. That was nonsensical and a duress alarm was pressed. SAPOL attended.36 The attending SAPOL officer described Mr Bombardieri as appearing drug affected. His pupils were pinpoint, his speech rapid, he was sweating profusely, and he was constantly moving. A search of Mr Bombardieri disclosed a small press bag containing a white 31 Exhibit C69, page 34

32 CBA 33 Exhibit C5 34 Exhibit C6 35 Exhibit C7 36 Exhibit C7

[2025] SACC 2 Deputy State Coroner White substance for which Mr Bombardieri received a drug diversion notice. He was also found to be in possession of 16 bank cards, including cards associated with the CBA.37 His behaviour that day could only be classified as bizarre. Whether the cause of the behaviour was a result of a mental health episode, drug use or a combination of both cannot be precisely determined. It is also not known why he had so many bank cards and whether it was true he was expecting a large amount of money from overseas. He may have been involved in criminal activity concerning the bank cards and accounts. If so, this would have been an additional stressor in his life. His note on the complaint form tended to suggest he felt under pressure.

Sunday 3 March 2019 Mr Bombardieri’s grandfather, Alfredo Dimasi, lived at 1488 with his wife Carmela.

Their daughter, Susanna Dimasi, was a frequent visitor at 1488.38 She was Mr Bombardieri’s aunt.

Mr and Mrs Dimasi and their daughter left 1488 at about lunchtime that day to visit friends. They returned at about 5:30pm. Mr Bombardieri was present at the rear of the property. His white Toyota van was parked in the driveway.39 Mr Bombardieri told his grandfather that ‘I have been calling everyone and no-one's picking up their phones’. Mr Dimasi had not received any calls from his grandson.

Importantly, Mr Bombardieri told his grandfather that he had been at the property for ‘about six hours’.40 Whether that was accurate or not, at the very least what I can find is that he was on the property on Sunday 3 March 2019 for an unknown period of time, alone.

Mr Dimasi invited his grandson into the house to have something to eat. Mr Bombardieri entered, but refused the food offered to him. His behaviour was ‘strange’. His grandfather asked him to leave, which he also refused. Mr Dimasi called his daughter, Maria Bombardieri. She called SAPOL to attend and remove her son, because he appeared to be unwell.41 SAPOL officers arrived at 1488 at 8:28pm. They were greeted at the door by Susanna Dimasi. Ms Dimasi told them that 1488 was a ‘safe haven’ for Mr Bombardieri. She reported he had ‘threatened with a spade’, the inference being that Mr Bombardieri made a threat towards his grandfather.42 37 Exhibit C20 38 Exhibit C9 39 Exhibit C9; the white van 40 Exhibit C8 41 Exhibit C10 42 Exhibit C63j

[2025] SACC 2 Deputy State Coroner White Probationary Constable Dinunzio spoke to Mr Bombardieri at the rear of the property.

The body worn video43 does not catch what Mr Bombardieri is saying. However, what can be heard at the beginning of the conversation is Mr Bombardieri saying, ‘we're already here together’ and ‘everyone's already been told’.44 Neither of those statements appeared to be in any context, or to make any sense. Mr Bombardieri, when questioned about illicit drug use, said that he had been clean ‘for a while now’. When asked to clarify that he said, ‘everyone has received advice about this’.45 Ultimately Mr Bombardieri retreated from engagement with SAPOL. An ambulance was called. Likewise, he did not engage with the ambulance officers and was detained under section 56 of the Mental Health Act 2009. Shortly after 9:30pm Mr Bombardieri was placed in the ambulance and transported to the Lyell McEwin Hospital.46 SAPOL collected Mr Bombardieri's property which the Dimasi's had located outside and placed in the kitchen. This included a pipe for smoking methylamphetamine.47 The Shed at 1488 Located at the rear of 1488 was a large shed. Mr Dimasi did not lock the shed.48 A gun safe welded to the internal door frame was on the southern side.49 In the gun safe Mr Dimasi stored a single barrel shotgun, an air rifle and the Fabrique rifle. The keys to the gun safe were kept under a hessian bag in the shed.50 Mr Dimasi said that no-one knew where he kept the keys.51 Lyell McEwin Hospital Shortly after Mr Bombardieri arrived the LMH he became agitated. A Code Black was called at 11:25pm. Mr Bombardieri was mechanically restrained and administered intramuscular droperidol. Those restraints were removed approximately one hour later.52 No samples of blood were taken, and Mr Bombardieri refused to provide a specimen for urinalysis. He remained uncooperative with staff the following morning. Maria Bombardieri called the LMH on the morning of 4 March 2019.53 In that call she expressed concern for her son and ‘fears about the grandparents that they might be abused by the patient’.54

43 BWV 44 Exhibit C63j 45 Exhibit C26 46 Exhibit C26 47 An ‘ice pipe’ 48 Exhibit C35 49 Exhibit C61, see photographs 1764, 1765, 1767 & 1769 50 Exhibit C61a, see photographs 1774 & 1775 51 Exhibit C8 52 Exhibit C70, pages 20-21; droperidol is an antiemetic, also used to reduce agitation is acute psychotic episodes 53 Exhibit C10 54 Exhibit C70, page 11

[2025] SACC 2 Deputy State Coroner White Patricia Strange was a nurse within the Psychiatric Liaison Service at the LMH. She received notification that Maria Bombardieri had called and called her back.

Mrs Bombardieri was keen that her son be admitted.55 Ms Strange told Maria Bombardieri that her son had a drug problem, not a mental health problem and that they could not force him to undergo treatment for his drug problem.56 A mental state examination was conducted. Ms Strange determined that Mr Bombardieri was not experiencing any thought disorder or perceptual anomalies, and that he had the capacity to make decisions. Ms Strange discussed the results of her examination, including outlining his psychiatric and forensic history, with the senior psychiatric registrar, Dr Szabo. There is no written record in the LMH notes of either the examination or the discussion with Dr Szabo.

Mr Bombardieri's care and control order under the Mental Health Act was lifted, and he was released from the LMH at 11:15am on Monday 4 March 2019.57 Events at 1488 - 4 March 2019 On the morning of Monday 4 March 2019, Mr Dimasi had contacted his daughter and asked her to collect Mr Bombardieri's white van which was still at 1488. Mr and Mrs Bombardieri drove to 1488, Mr Bombardieri Snr then drove the white van to 47 Golding Road.

Mr Bombardieri arrived at 1488 whilst his mother was present.58 It is not known how he arrived, but it is reasonable to assume he caught a taxi or Uber. Mr Bombardieri had no money when admitted to the LMH but had 16 bank cards.59 Mr Bombardieri did not enter the house, but he obtained a drink from the shed and waited at the front of the property until he was collected by a taxi and driven to 47 Golding Road, arriving at 12:28pm.60 6 March 2019 At 2pm on 6 March 2019 Mr Dimasi contacted SAPOL on 131 444 and reported that his grandson had ‘pinched my rifle’. Mr Dimasi identified his grandson as 'Marco Bombardieri' and that it had occurred on the previous Sunday.61 The report was categorised as a 'theft'. SAPOL gave the report a priority 3 status.

Acting Inspector McDonald,62 the duty officer of EPS that afternoon, gave evidence that Mr Dimasi reported he had called SAPOL because he woke up from a nap during which ‘he'd had a vision or a belief that his grandson had removed a firearm from his gun safe’.63 55 Exhibit C10 56 Exhibit C11 57 Exhibit C70, page 17 58 Exhibit C10 59 Exhibit C70, pages 15 & 25 60 Exhibit C63 61 Exhibit C24, Annexure B, page 1; Exhibit C63m, call 17777 62 AI McDonald 63 Transcript, page 42

[2025] SACC 2 Deputy State Coroner White Mr Dimasi's call to SAPOL lasted for eight minutes. At no point during that call did Mr Dimasi say anything about having a vision whilst asleep or anything that could be so interpreted.64 This call came to the attention of Inspector Robinson who was very near the end of his shift. His duties were to be taken over by AI McDonald.

At 2:07pm Sergeant Cunningham, patrol supervisor at Salisbury, became aware of the theft reported by Mr Dimasi. He caused the State Shift Manager, the Duty Inspector Andrew Robinson, the Northern CIB and the Firearms branch to be notified.65 Maria Bombardieri, having spoken with her father, rang SAPOL at about 2:20pm and advised them of the white van her son drove, together with the concerns she felt for her parents at 1488.66 As a result of that call, Sergeant Cunningham caused a ‘Keep Look Out For’67 for Mr Bombardieri and the white van, to be broadcast on all SAPOL channels.68 Sergeant Ryan Nicholls At 2:39pm a SAPOL ‘cover’ patrol was dispatched to 1488. Sergeant Cunningham then briefed AI McDonald and the on-coming patrol supervisor, Sergeant Nicholls.

Sergeant Nicholls then spoke with Constable Lilyman who was present at 1488.

Constable Lilyman indicated that there may be a broader timeframe for the alleged offending than contained in the report to SAPOL.69 Sergeant Nicholls became aware of SAPOL intelligence concerning Mr Bombardieri's possible possession of a handgun the previous January.70 He was also aware that SAPOL had interacted with Mr Bombardieri at a bank at Findon the previous Friday 1 March 2019, as well as detaining him on Sunday 3 March 2019.71 Sergeant Nicholls also had personal knowledge of Mr Bombardieri, having arrested him in 2015.72 As a result of this personal knowledge and his research of available SAPOL records, Sergeant Nicholls, quite properly, formed the view that Mr Bombardieri was not a fit and proper person to be in possession of a firearm.73 That opinion never changed.74 When he was asked, having formed that state of mind and having an address for Mr Bombardieri, 64 Exhibit C63m, call 17777 65 Exhibit C31 66 Exhibit C63, calls 17813 & 17839

67 KLOF 68 Exhibit C31 69 Transcript, page 157 70 Transcript, page 159 71 Transcript, page 158 72 Transcript, page 161 73 Transcript, page 160 74 Transcript, page 178

[2025] SACC 2 Deputy State Coroner White for SAPOL to at least do a drive by of that address to see if he or his vehicle was present, Sergeant Nicholls gave the following response: ‘Those options were a consideration. However, my concern was, on my previous interactions I've had with Mr Bombardieri, that, if we were to alert him that police were present, it may trigger an unwanted course of action, and that, while it seems apparent and reasonable to conduct a welfare check, I couldn't ignore the fact that he might have a firearm as well.’ 75 When pressed further regarding performing a ‘drive by’ of the address, Sergeant Nicholls maintained that it was ‘always a risk on how it's conducted’.76 Sergeant Nicholls agreed that before he left the Salisbury Police Station to travel to 1488, that there was a necessity to locate Mr Bombardieri. He agreed it was a question ‘of when’, not if, attempts would be made to locate him.77 Following his discussions with Constable Lilyman after her return to the Salisbury police station, Sergeant Nicholls formed the view that there had been no escalation since Sunday 3 March 2019 and that gave some time to make further inquiries at 1488. Sergeant Nicholls was also aware that an unregistered air rifle had been located and left at 1488.

Sergeant Nicholls rejected SAPOL attendance at 1488 to seize the unregistered air rifle, as the ‘real motivation’ for his attendance, but said it complicated matters.78 Sergeant Nicholls engaged two further officers to assist with the breaches of the Firearms Act, to allow Constables Lilyman and Woodward to focus on the theft allegation and to conduct a search of 1488.79 Sergeant Nicholls rejected that he had formed a view before arriving at 1488 that Mr Dimasi was unreliable and people of a certain age, who reside rurally do not take security of firearms seriously. He did form a view on this general topic, not based upon Mr Dimasi's age, but more about persons who had possession of firearms for many years, particularly before the changes to the legislation, still acted as if the previous regime applied.80 Sergeant Nicholls had previously been stationed in rural South Australia.81 Sergeant Nicholls had some concerns when he was at 1488 about what Mr Dimasi was telling him.82 However, he accepted with hindsight that in Mr Dimasi’s mind it could have been as simple as his grandson was present on the property alone the previous Sunday and now the firearm was missing and his grandson must have been responsible.83 75 Transcript, page 161 76 Transcript, page 162 77 Transcript, page 162 78 Transcript, page 163 79 Transcript, page 172 80 Transcript, page 173 81 Transcript, page 154 82 Transcript, page 174 83 Transcript, page 175

[2025] SACC 2 Deputy State Coroner White At the time of his departure from 1488, Sergeant Nicholls was of the belief that his role was to consolidate the investigation for it to be handed over to the Volume Crime Section84 of the Elizabeth Criminal Investigation Branch.85 He arrived back at the Salisbury police station at 6:20pm.86 His evidence was he had a conversation with AI McDonald about the investigation being handed over to VCS. When asked when that conversation occurred, he said: ‘ ... but I remember the purpose of what we are trying to achieve at the property was to consolidate the investigation, complete the initial investigation and hand it over, so it was at the property at least.’ The next step contemplated by Sergeant Nicholl's was that 47 Golding Road would be searched under the Firearms Act by the VCS, whether Mr Bombardieri was present or not. He had that belief because of his interactions with AI McDonald.87 He and his team were not going to be involved in that search for many reasons, including 1488 was not in their patrol area,88 it was beyond their means and, due to the nature of the search, it would require planning and by inference, resourcing.89 Sergeant Nicholls spoke with Detective Sergeant Forrest of ECIB at 7:10pm by telephone.90 At that time Sergeant Nicholls firmly believed that Detective Sergeant Forrest had previously received a briefing from AI McDonald.91 That conversation with Detective Sergeant Forrest was, in Sergeant Nicholls’ mind, a handover of the investigation to the VCS. However, Sergeant Nicholls readily accepted that he never said those express words, or words to that effect, because he was acting on AI McDonald's advice.92 He called Sergeant Pope, as an ‘extra step’ in the handover to the VCS.93 He was concerned to a degree that after speaking with both Detective Sergeant Forrest and Sergeant Pope that there was not going to be a search that night. He did not express that concern to anyone, because this investigation, in his mind, was now the provenance of the VCS.94

84 VCS 85 ECIB 86 Exhibit C67 87 Transcript, pages 175, 176, 188, 189 88 Transcript, pages 176, 197 89 Transcript, page 176 90 Transcript, page 242; Exhibit C69 at [22] 91 Transcript, page 186 92 Transcript, pages 195-196 93 Transcript, page 197 94 Transcript, page 177

[2025] SACC 2 Deputy State Coroner White Detective Sergeant Kylie Forrest Detective Sergeant Forrest was called to a meeting with AI McDonald in his office at about 4:30pm. AI McDonald told her that she did not need to make any notes. This indicated to her that this was a ‘general discussion’ about a ‘job’.95 AI McDonald rejected that suggestion when it was put to him.96 Detective Sergeant Forrest left that meeting thinking VCS may be called later, either by AI McDonald or Sergeant Nicholls ‘to provide assistance with a search’.97 Sergeant Nicholls called Detective Sergeant Forrest at 7:10pm. At the completion of that call, Detective Sergeant Forrest believed that VCS would be a resource to assist in a search under the Firearms Act if Mr Bombardieri was located. Detective Sergeant Forrest did not say the Sergeant Nicholls had used language expressly handing over the investigation to VCS.98 Acting Inspector McDonald AI McDonald was the duty officer at EPS in March 2019. His duties in that position were to ‘provide supervision, advice’, ‘to attend scenes to give direction, provide control … and provide authorities in relation to certain powers and legislating authorities…’.99 On 6 March 2019, his shift was due to begin at 3pm but he had arrived early at about 2:20pm. He received information that a report via phone had been made about a missing firearm at 1488 and the owner’s grandson as a possible culprit. The source of this information was reported as a ‘vision or belief that his grandson had removed a firearm from his gun safe or his gun storage compartment. He’d gone out to check the safe and the firearm was missing.’100 This caused AI McDonald to conduct checks about Mr Bombardieri on the SAPOL computer systems. He also attended at 1488 that afternoon. This is after viewing BWV footage of the SAPOL officers’ attendance on 3 March 2019.101 He was aware of the bizarre episode at the CBA at Findon on 1 March 2019. There were ‘flags’ in the system about mental health issues, drug use and possession of a small pistol on 19 January.102 Upon attendance at 1488, AI Mc Donald inspected the gun safe. He described it as ‘very small’ and had doubts whether ‘the missing gun would actually fit in the safe with the other two guns’.103 Another factor he took into account at the time about the accuracy of 95 Transcript, page 235 96 Transcript, page 94 97 Transcript, page 236 98 Transcript, page 244 99 Transcript, page 35 100 Transcript, page 42 101 Transcript, pages 45-46 102 Transcript, pages 49-51 103 Transcript, page 52

[2025] SACC 2 Deputy State Coroner White the information was his experience that thieves of a firearm, or any item in general, do not remain at the crime scene as Mr Bombardieri did on 4 March 2019.

Despite these misgivings, AI McDonald confirmed SAPOL’s ‘intention always along was to conduct a firearms search in relation to Mr Bombardieri. That’s what we were moving towards’.104 He also highlighted the need for SAPOL to exclude that it was not a situation of Mr Dimasi misplacing the Fabrique rifle within 1488. The firearms search regarding Mr Bombardieri was planned for that evening.105 I have carefully considered his evidence including his dealings with Detective Sergeant Forrest and Sergeant Nicolls and his overall strategy in dealing with this investigation on 6 March 2019. I have carefully avoided applying hindsight bias and outcome bias to his evidence.

In the end, I find his analysis, actions and directions, whilst not perfect, were reasonable.

However, I do accept the evidence of Detective Sergeant Forrest and Sergeant Nicholls where it differs from his memory as I find their recollection of events was more precise.

This does not mean AI McDonald was trying to mislead the Inquest in his evidence.

47 Golding Road On 6 March 2019 there were six persons living at 47 Golding Road. Mr Bombardieri occupied bedroom number 3 under the main roof.106 The occupants were individual renters. It was, in effect, a boarding house. There did not appear to be any social network amongst this group.

Mr Bombardieri was seen by fellow resident Adam Blatchford shortly after 9am getting into his white Toyota van. Mr Bombardieri smiled and waved to Mr Blatchford.107 Mr Bombardieri was next seen at the property between 5pm and 6pm when he walked past Shane Hann without speaking.108 He was heard trying to start his motorbike outside Mr Hann's bedroom window shortly thereafter.

Mr Blatchford was in the communal kitchen at about 6:30pm preparing his dinner when Mr Bombardieri entered the house via the rear door. He was described as not being his cheerful self. He was carrying an item that looked like an umbrella coloured yellow and red. The two men exchanged pleasantries and Mr Bombardieri proceeded to walk into his room and shut the door loudly.109 This was the last time Mr Bombardieri was seen alive.

104 Transcript, page 52 105 Transcript, page 59 106 Exhibit C65 107 Exhibit C12 108 Exhibit C14 109 Exhibit C12

[2025] SACC 2 Deputy State Coroner White At 7:30pm a neighbour knocked on the front door. Mr Blatchford answered the knock.

The neighbour said that the lights on the white van had been left on. Mr Blatchford knocked on Mr Bombardieri's door but there was no answer. Mr Blatchford described what he heard when he knocked on the door: ‘I could hear a sound coming from inside of Mark's bedroom which sounded different compared to someone snoring. It sounded like difficult breathing, like a snarling sort of sound. I assumed it was him sleeping.’ None of the occupants of 47 Golding Road heard a gunshot.

SAPOL attendance at 47 Golding Road Maria Bombardieri received a call from her son, Matthew, who had driven past 47 Golding Road, saying that Mr Bombardieri's van was present, the lights were on, with the engine running. Maria Bombardieri then made an anonymous call to SAPOL advising them of the same and that the owner of the van was suspected of having stolen a firearm.110 A SAPOL patrol was tasked to the address. Sergeant Newman of Parks Patrols took command of the tasking and organised patrols to attend a cordon point and not attend at the property.111 Ultimately, after direction from Duty Inspector Karmen Conway, SAPOL entered the property under the Firearms Act at 10:20pm and found Mr Bombardieri deceased.112 He was cold to the touch.113 SAPOL General Order for Firearms Lost or Stolen On a report being received of a lost or stolen firearm, the Officer in Charge of the relevant CIB area must be made aware, 'so an investigator can be assigned'. Next, SAPOL must attend the scene unless exceptional circumstances exist not to do so. During that attendance SAPOL must conduct an audit to reconcile the remaining firearms and ensure that they are stored in accordance with the Firearms Act Regulations. If either the Firearms Act or its regulations have been breached, ‘appropriate enforcement action must be taken’.114 Sergeant Nicholls complied with the General Order. It also may have subconsciously at least contributed to his belief that he was handing over the investigation to VCS in the telephone call made at 7:10pm, though he did not give specific evidence of that.

110 Exhibit C10 111 Exhibit C40 112 Exhibit C52 113 Exhibit C41 114 Exhibit C63g, page 36

[2025] SACC 2 Deputy State Coroner White Discrepancies between Detective Sergeant Forrest and Sergeant Nicholls Detective Sergeant Forrest and Sergeant Nicholls were known to each other professionally.115 Sergeant Nicholls was a man that Detective Sergeant Forrest said she could trust.116 There were a number of discrepancies in their respective evidence concerning the contact they had with each other on the evening of 6 March 2019. In the normal course of events, I would embark on the task to make findings as to which witness I accepted. However, in this matter, we have two diligent SAPOL officers known to each other and of whom neither has cast any aspersions against the other in their respective evidence. I am not inclined to find for or against either of them for the reasons set out below.

What is plain is that the two officers had a telephone conversation where each of them had a previous conversation, with AI McDonald, where the other was not present.

Consequently, each party to the telephone conversation at 7:10pm came to it with preconceived beliefs as to their role and the purpose of the telephone call. Sergeant Nicholls did not expressly hand over the investigation to VCS because he thought they already understood that was the purpose of the call at 7:10pm. Likewise, Detective Sergeant Forrest did not expect him to hand over the investigation to her, as her role (VCS's role) was to assist with a search if called upon.

Conclusions I find that both Sergeant Nicholls and Detective Sergeant Forrest were frank, honest and compelling witnesses.

I accept that Sergeant Nicholls' evidence that Mr Bombardieri should not have been approached until proper planning and resources were in place to prevent or minimise the risk to Mr Bombardieri, SAPOL and the public, in particular the other household members, was logical and correct.

It is a common everyday occurrence in interactions between people that they individually come away with a different perspective of the interaction. This phenomenon should be avoided as much as possible with SAPOL in these types of situations.

As Detective Sergeant Forrest agreed, this was simply a misunderstanding between two professional SAPOL officers.117 Conscious of that, Detective Sergeant Forrest has sought to take advice and steps to ensure such misunderstandings do not occur in the future.118 This misunderstanding is not the result of some structural or systemic failing within SAPOL. Naturally, it would have been preferable if both could have been present, or at 115 Transcript, pages 176, 257 116 Transcript, page 257 117 Transcript, pages 257-258 118 Transcript, page 255

[2025] SACC 2 Deputy State Coroner White least been able to hear clearly by phone or SAPOL Communications when AI McDonald gave his directions to them.

I find that Mr Bombardieri had inflicted the gunshot wound to his right temple prior to Mr Blatchford knocking on his door at 7:30pm, when he heard what he interpreted as ‘difficult breathing’.

It is known that Mr Bombardieri survived the infliction of the gunshot wound because of the presence of positive APP axonal changes within the brain.119 It is considered that the minimum period of survival necessary for the APP axonal changes to be demonstrated on histochemical staining, is 35 minutes after the infliction of the cerebral insult.

It can never be precisely known at what time Mr Bombardieri inflicted the gunshot wound from 6:30pm when he was seen going into his room and the sounds that Mr Blatchford heard at 7:30pm. However, for all practical purposes it was too late when the telephone call occurred between Sergeant Nicholls and Detective Sergeant Forrest at 7:10pm.

It is important to remember that Mr Bombardieri did not have any knowledge that his grandfather had found that the firearm was missing, and that he had contacted SAPOL at 2pm. He did not know that SAPOL were present at 1488 making enquiries and conducting a search. If the absence of the firearm had been detected 24 hours earlier,120 given Mr Bombardieri had no knowledge, it is very likely that a properly planned and resourced search would have taken place of 47 Golding Road, Mr Bombardieri and his van, well before 6:30pm on 6 March 2019, thus preventing his suicide by gunshot. There was only 4½ hours between the call from Mr Dimasi at 2pm and Mr Bombardieri entering his room at 6:30pm, after which it was too late to prevent the ultimate outcome.

It is reasonably open, and indeed probable, to find that Mr Bombardieri took the Fabrique rifle out of the gun safe on Sunday 3 March 2019, when he was present on the property for probably hours alone and placed it in his van. I also am comfortably satisfied that his father, unaware of its presence, transported the Fabrique rifle to 47 Golding Road when he drove the white van from 1488 on Monday 4 March 2019, at the request of Mr Dimasi.

I find Mr Bombardieri's death was not preventable in all the circumstances.

SAPOL investigation of its own conduct in relation to the death of Mr Bombardieri SAPOL investigated the actions and communications of its officers concerning Mr Bombardieri from 3 March 2019 until finding him on 6 March 2019.121 This SII was provided to the Inquest.122 It is a comprehensive summary of key events involving SAPOL on 3 March 2019, and particularly 6 March 2019. AI McDonald’s 119 Exhibit C4b, page 2; APP stands for beta-amyloid precursor protein 120 It is not suggested that it should have been or that Mr Dimasi should have taken some earlier step 121 Significant Incident Investigation - SII 122 Exhibit C64, Report of SII dated 14 December 2021

[2025] SACC 2 Deputy State Coroner White orders are reviewed in relation to the applicable General Orders. It made several recommendations on the following topics: Policy of SAPOL responses regarding the level of urgency for calls for 1.

assistance for all reported firearms offences should be upgraded.

Reviews of individual officers’ actions regarding compliance with relevant 2.

General Orders.

A review of ‘General Orders Firearms’ to include further detailed instructions 3.

relating to the investigation of loss or theft of firearms.

Upgrading firearms offences to be within the definition of serious crime for the 4.

‘General Order Crime and Occurrence Reporting’.

A review into whether mandatory firearms checks be performed when SAPOL 5.

attend for ‘high risk and emotive events’.

Due to this thorough SII report and its recommendations for review, I do not wish to make any recommendations other than to endorse the recommendations in that report to be adopted by the Commissioner of Police.

Keywords: Suicide; Firearms; Police