Coroner's Finding: Mason, Geoffrey

FINDINGS, COMMENTS and RECOMMENDATIONS of Coroner McTaggart following the holding of an inquest under the Coroners Act 1995 into the death of: Geoffrey Russell Mason

Table of Contents Breakdown of the relationship with Ms Gard and its impact on Mr Mason’s mental health

The number of shots fired by Sergeant Conyers and Constable Mitchell and their points of Did Sergeant Conyers fire at the vehicle driven by Mr Mason rather than Mr Mason himself?

Record of Investigation into Death (With Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Olivia McTaggart, Coroner, having investigated the death of Geoffrey Russell Mason with an inquest held at Hobart in Tasmania make the following findings.

(These findings have been de-identified in relation to family by direction of the Coroner pursuant to s57(1)(c) of the Coroners Act 1995) Hearing dates 9, 14, 15 December; 3, 4, 5, 6 April 2023; 10 May 2023 Representation Counsel Assisting the Coroner: J Ransom and E Brett Counsel for the Commissioner of Police: M Miller and N Pearce-Rasmussen Counsel for Constable Tim Mitchell and Sergeant Brad Conyers: G Wood Counsel for Ms Jennifer Bishton: G Melick SC and C Graves Introduction

1. Mr Geoffrey Russell Mason, aged 38 years, died on 17 February 2020 as a result of a gunshot wound to the neck. The shot was fired by a police officer in the performance of his duties. Mr Mason had been involved in an altercation at 233 Tea Tree Road, Brighton where he resided with his sister Karen Maguire, her husband Wayne Maguire and their son. Due to Mr Mason’s level of aggression, Mr and Mrs Maguire had called for urgent assistance to remove him from the residence. The three officers of Tasmania Police who arrived were attempting to detain Mr Mason at the time he was shot.

2. A thorough coronial investigation was commenced into Mr Mason’s death as well as a separate investigation run by Professional Standards into the conduct of three officers in attendance.

3. Section 24(1) of the Coroners Act 1995 (the Act) provides, relevantly, that: “… a coroner who has jurisdiction to investigate a death must hold an inquest if the body is in Tasmania or it appears to the coroner that the death, or the cause of death, occurred in Tasmania or that the deceased ordinarily resided in Tasmania at the time of death and – … (e) the death occurred in the process of a police officer….attempting to detain a person;”

4. Mr Mason’s death occurred in the process of police officers attempting to detain him.

An inquest is therefore mandatory under the Act.

5. Under section 28(1) of the Act a coroner investigating a death must find, if possible:

(a) the identity of the deceased; and

(b) how death occurred; and

(c) the cause of death; and

(d) when and where death occurred.

6. Further, by section 28(2), a coroner must, whenever appropriate, make recommendations with respect to ways of preventing further deaths and on any other matter that the coroner considers appropriate.

7. By section 28(3), a coroner may comment on any matter connected with the death including public health or safety or the administration of justice.

8. Section 28(5) requires a coroner to report on the care, supervision or treatment of the person while the person was a person held in custody. In this regard, the question of whether Mr Mason was actually “held in custody” is not without difficulty. Pursuant to section 3 of the Act, Mr Mason would be held in custody if he was, immediately before his death, in the control of one or more police officers.

9. In the circumstances of this case, the better view is that Mr Mason was not under the requisite degree of control envisaged by this definition and was therefore not “held in custody”. As a consequence, there is no mandatory requirement imposed by section 28(5). However, such interpretation makes little difference to the coroner’s task. In such a case as this, it is inevitable that the investigation and these findings will focus upon the actions of the police officers and whether Mr Mason’s death could have been reasonably prevented. The scope of the inquest, as set out below, illustrates the point.

Scope of inquest

10. The particular focus of this inquest was upon the following matters;

(a) The cause and circumstances of death;

(b) Mr Mason’s background including;

(i) Medical and psychiatric history; (ii) Previous interactions with Police;

(c) Information and support provided to attending police including;

(i) The unfolding events at 233 Tea Tree Road Brighton; (ii) Mr Mason’s background;

(d) Response and planning of attending police including;

(i) The location of any rendezvous; (ii) Discussions between attending police; (iii) The factual and legal basis for the attending police entering 233 Tea Tree Road;

(e) The use of body-worn cameras by attending police including;

(i) General body camera operation limitations as at 17 February 2020; (ii) Specific training of the attending police; (iii) Overarching police policy and training; and (iv) Any changes in policy and/or training since 17 February 2020;

(f) The tactical decisions of attending police including;

(i) Sergeant Conyers decision to get out of the police vehicle and draw his firearm; (ii) Sergeant Conyers decision to fire at Mr Mason’s vehicle; (iii) The number of shots fired by Sergeant Conyers and their points of impact; (iv) The deployment of road spikes by Constable Chowdhury;

(v) The decision of Constable Mitchell to fire at Mr Mason; and (vi) The number of shots fired by Constable Mitchell and their points of impact;

(g) The firearms training and firearms validation of attending police officers; and

(h) The medical assistance rendered to Mr Mason by the attending police officers.

Evidence in the investigation

11. The documentary exhibits comprising the investigation were tendered at the inquest and were labelled CA and C1 to C75(b). The exhibit list is attached to this finding and marked with the letter “A”.

12. Oral testimony was given at inquest by the following witnesses:

• Ana Flonta – Forensic Scientist (C60a, C60b and C60c);

• Claire Fulton – Forensic Scientist (C54a and C54b);

• Neil McLachlan-Troup – Forensic Scientist (C7a and C7b);

• Dr Donald Ritchey – State Forensic Pathologist (C5);

• Constable Kelly Cordwell – Crash Investigation Services (C37);

• Sergeant Gerard Dutton – Ballistics (C36);

• Sergeant Loretta Ashwood –Tasmanian Police Operational Skills Unit (C66);

• Sergeant Steve Herbert – Professional Standards (CA);

• Dr Soon Hock Chong – General Practitioner (C43);

• Jennifer Bishton – Mother of Mr Mason (C12 and C13);

• Wayne Maguire – Brother-in-law of Mr Mason and resident of 233 Tea Tree Road (C8 and C9);

• Karen Maguire – Sister of Mr Mason and resident of 233 Tea Tree Road (C10 and C11);

• Joseph Jones – Friend of Mr Mason (C18);

• Sharon Gard – Former partner of Mr Mason (C17);

• Constable Rod Warrington – Operational skills instructor at the Tasmanian Police Academy (C70a, C70b and C70c);

• Constable Abu Chowdhury – Attending police officer (C27);

• Constable Tim Mitchell – Attending police officer (C23 and C24); and

• Sergeant Brad Conyers – Attending police officer (C25 and C26).

13. In this finding, I have set out various quotes from passages of evidence or interviews. I have not marked or highlighted the grammatical errors present in the original passages.

Background

14. Geoffrey Russell Mason was born on 26 September 1981 to parents Jennifer Anne Bishton and Christopher Charles Mason.

15. Mr Mason’s mother, Ms Bishton, described Mr Mason as a “different” child who had issues fitting in at school. He was subsequently diagnosed with attention deficit hyperactivity disorder for which he was prescribed Ritalin. Ms Bishton described Mr Mason as being prone to “blow outs” of anger while at other times being “super sensitive”.

16. Ms Bishton detailed a specific incident when Mr Mason was attending Kingston Primary School. Mr Mason believed he was in trouble for stealing a female student’s hat in the school yard. In accordance with an agreed strategy urged on Mr Mason by his treating medical professionals, Mr Mason left the school grounds before returning to the classroom. However, he was then physically restrained by a number of male teachers and taken to the principal’s office where he attempted self-harm with a pen or pencil.

Police were called and attended the school. Ms Bishton vividly recalled attending the school to find Mr Mason handcuffed to a chair. It may be that that this incident played a part in Mr Mason developing a distrust of police from a young age.

17. Mr Mason did not complete high school but did participate in some adult education.

18. Mr Mason developed significant issues with the use of alcohol at a young age, and unfortunately, his excessive use of alcohol was a constant problem throughout his life.

Ms Bishton described her son as having a long history of mental health issues and selfloathing. She said that, as a younger adult, he had slashed his wrists, damaged his hands and tried to hang himself.

19. At various times between 2004 and 2011, Mr Mason resided in Victoria where he began using heroin intravenously. It is likely that the use of needles to inject heroin led to Mr Mason being diagnosed with Hepatitis C.

20. In about 2013, after serving a term of imprisonment for crimes of violence in Victoria, Mr Mason returned to Tasmania and resided at 233 Tea Tree Road, Brighton. At this address he lived with his sister, Karen Maguire, and her husband, Wayne Maguire. Mr and Mrs Maguire’s son, XY, also lived at the address and was 7 years of age at the time of Mr Mason’s death.

21. After returning to Tasmania, Mr Mason continued to have issues with alcohol, as well as his mental health. He received significant help and support with these issues from his family. It is clear that his mother, Ms Bishton, provided a great deal of support and help to her son over his life. She was able to assist the investigation with a great deal of information concerning Mr Mason’s considerable struggles with his mental health, substance abuse and relationships over the course of his lifetime.

Mr Mason’s previous interactions with police

22. Mr Mason had significant prior convictions in Tasmania, Victoria and Queensland which involved interactions with police. He also had incidents recorded on police systems involving threats of violence.

23. In 1996 Mr Mason was convicted in Tasmania of resisting police. In 2003, he was convicted of two charges of common assault, injuring property and refusing to state his name and address. For the 2003 offences he received a suspended term of imprisonment. The matter involved an unprovoked attack on two members of the public, who attempted to assist Mr Mason when they found him lying on a Devonport Street in a dazed state.

24. Police information systems record that Mr Mason threatened police with an axe on 27 March 2001.

25. It is further recorded that on 19 April 2003 police attended an attempted suicide by Mr Mason that resulted in him being assessed at the Royal Hobart Hospital (RHH) during which he threatened medical staff and police. This resulted in a warning being placed on the intelligence system that Mr Mason may attempt suicide in the presence of police.

26. In 2010 Mr Mason was convicted of an assault upon a police officer occurring on 21 February 2004 for which he was sentenced to a further suspended term of imprisonment. The facts of that assault involved Mr Mason wiping blood on the forearm of the arresting officer and stating: “I’ve got AIDS and I hope you get it too”. This was at a time when Mr Mason knew he was hepatitis C positive.

27. On 27 May 2011, Mr Mason was sentenced in Victoria to a three year term of imprisonment for crimes of affray and intentionally causing serious injury. The incident involved a joint attack on the victim by Mr Mason and two other offenders. Following

an assault by his co-offender that rendered the victim unconscious, Mr Mason and the third offender kicked the victim to the head. A witness described the kick administered by Mr Mason to be “as hard as he could”. The victim was found to have bruising to his body and head, a fractured skull, and bleeding on the brain. He suffered permanent neurological injuries as a result of the assault.

28. Mr Mason’s history of offending and interactions with police is evidence that he had a history of engaging in behaviour of a violent nature.

Mr Mason’s health Health in the years before death

29. From 2014, Mr Mason’s primary general practitioner was Dr Soon Hock Chong of the Sorell Medical Centre.

30. Mr Mason’s mental health and alcohol abuse continued to be very significant issues for him and obviously ones which caused him distress and impaired his functioning.

31. Between January 2014 and February 2020, Mr Mason attended 32 consultations at the Sorell Medical Centre. The consultations related to his conditions including Hepatitis C, asthma, back pain, alcohol abuse, general anxiety disorder and depression.

32. On 3 December 2019, RHH records indicate that Mr Mason had attended the hospital after he had been vomiting for two days from binge drinking. This was associated with the breakdown of his relationship with Sharon Gard. Mr Mason was also charged by police with damaging Ms Gard’s mobile phone and assaulting her.

33. Dr Chong’s notes of 5 December 2019 record Mr Mason as being depressed and anxious, but not attempting to self-harm nor displaying any suicidal ideation. His dosage of Endep (a tricyclic anti-depressant) was reduced, and a prescription for sertraline (an anti-depressant) was added. A prescription for diazepam (a sedative) was continued.

34. On 5 February 2020, Mr Mason again consulted Dr Chong. Dr Chong recorded Mr Mason’s mood as still anxious, depressed and feeling jittery. He questioned whether there was an apparent adverse reaction to sertraline. That prescription was ceased.

35. A prescription for paroxetine (anti-depressant) was added and prescriptions for Endep and diazepam were continued.

36. In his oral evidence, Dr Chong told the inquest that a change in anxiety and/or depression medication commonly results in a patient initially feeling worse for a period.

Attendance at the RHH on 11 and 12 February 2020

37. In the days leading up to his death, Mrs Maguire and Ms Bishton both described Mr Mason’s mental health as deteriorating to the point that he was regularly expressing suicidal ideation. They both took Mr Mason to the RHH Emergency Department at 10.00pm on 11 February 2020. He remained at the hospital until 3.14pm on 12 February 2020.

38. The Emergency Department notes record that Mr Mason presented with depression, noting, “He wants to kill himself. States he plans to run in front of a car. Has had recent changes to medications, has been actively suicidal for 3/7. Sister in attendance. Main - Depressive episode.”

39. At 6.34am on 12 February 2020, the nursing notes record: “Discussion with patient’s mother re waiting time and treatment for patient. Patient has been waiting for eight+ hours due to severe access block and acuity of department.

Mother teary as worried about patient as he was expressing suicidal ideation and had active plans to kill himself. Patient and mother disclosed to writer that he had been hitting his head while in the waiting room bathroom and knocked himself out, then was planning to jump off carpark ramp. Writer strongly advised the patient and his mother to inform the nursing staff when actively thinking of hurting himself so that staff can escalate his care. Patient stating that his anxiety is “through the roof”, stat diazepam given. Reassurance ++ provided.”

40. At 9.04am, Mr Mason was seen by an Emergency Department doctor, who referred Mr Mason for a psychiatric assessment. After consultation between nursing staff and a locum psychiatrist, Mr Mason departed the RHH at 3.14pm on 12 February 2020. A referral was made to the Crisis Assessment and Treatment Team (“CAT team”).

41. Prior to Mr Mason’s death, the CAT team attempted unsuccessfully to make contact with him by calling his mobile phone. Contact was, however, made with Ms Bishton who undertook to pass on the message for Mr Mason to contact the CAT team.

42. Mr Mason did not make contact with the CAT team prior to his death on 17 February 2020.

43. On 13 February 2020, the RHH sent a summary of Mr Mason’s attendance at the hospital to Dr Chong. Subsequent to his oral evidence, Dr Chong confirmed having received this summary. However, Mr Mason’s last in-person appointment with Dr Chong occurred on 5 February 2020, which was before his hospital attendance.

Breakdown of the relationship with Ms Gard and its impact on Mr Mason’s mental health

44. It is clear from the evidence of Ms Bishton and Mrs Maguire, that both believed that the breakdown of Mr Mason’s relationship with Ms Gard was a major factor in the deterioration of his mental health. I agree that the difficulties associated with this relationship impacted upon Mr Mason’s mental health leading to his death.

45. On 28 November 2019, Ms Gard reported to police that Mr Mason had assaulted her and broken her mobile phone. This led to Mr Mason being served with a summons for charges of assault and damage to property.

46. In her interview with police on 18 February 2020, Ms Maguire stated; “Sharon’s his ex who claimed that he hit her ….he had been quite upset because he said he didn’t want to go to jail for something he didn’t do. So he just smashed the phone and I think he’d kicked the door and then Sharon had been, for months, sending me messages and Geoffrey messages saying the police said that if we talk um, they’ll drop the charges, you know, just verbal threats.”

47. In her interview of 21 February 2020, Ms Bishton described Mr Mason’s admission to the RHH on 3 December 2019 as being directly associated with the relationship breakdown. She stated: “I’d taken Geoffrey to the hospital because he tried to drink himself to death that week, wasn’t it? We, and he got to the point where he could not stop vomiting and he spent three days in hospital because his liver levels were out a whack and he was, and driving him home that day he told me he was going to kill himself.”

48. Ms Bishton further stated that Mr Mason said to her before Christmas 2019 “Mum I’m not going down for something I haven’t done. I smashed her phone I threw the birdcage and I’m not going down for something I didn’t do, I’ll kill myself first”.

49. Examination of Mr Mason’s mobile phone by the Tasmanian Police Digital Evidence Unit revealed that between 28 November 2019 and 17 February 2020, Ms Gard texted Mr Mason some 865 times. Ms Gard agreed to this during her oral evidence at the inquest.

50. This text contact from Ms Gard continued until the day of Mr Mason’s death, when she attempted to arrange a meeting with him.

51. Ms Gard gave evidence at the inquest and told the court that her last telephone contact with Mr Mason was some time in the afternoon of 17 February 2020. She said that she asked him to come to her house to discuss the current charges against Mr Mason in which she was the complainant. Ms Gard stated that Mr Mason gave her no indication that he was suicidal. I cannot make a finding as to whether Ms Gard did have this conversation with Mr Mason. She was not a credible witness and could not provide a consistent or reliable account to the court. I do not accept her evidence where it is not corroborated by other evidence.

52. The last confirmed telephone contact from Ms Gard was at 9.23pm on 17 February 2020 when she left a message: “Hey it’s just me just seeing how you went somewhere to stay I hope you’re alright OK bye.” Mr Mason was deceased by this time.

53. I am satisfied that the constant contact initiated by Ms Gard with Mr Mason was largely unwanted by him and that it contributed significantly to the downturn in his mental health before his death. Ms Bishton specifically described her son’s anger and mood swings as becoming worse since he became involved with Ms Gard.

54. I am satisfied that Mr Mason’s suicidality in the three months before his death coinciding with the breakdown of his relationship with Ms Gard, was at a high level. His suicidal ideation appears to have become chronic and, on different occasions, he spoke of numerous plans regarding how he would end his life.

55. I am satisfied that Dr Chong provided Mr Mason with good and diligent care. I note that on 5 December 2020, he completed a mental health care plan for Mr Mason and made a mental health referral for him. It does not appear that Mr Mason then took steps to

arrange the appointment. It also seems that Mr Mason did not disclose to Dr Chong the extent of his alcohol consumption and suicidality.

56. I do not accept the suggestion raised by Mr Mason’s family that the cessation of Mr Mason’s antidepressant, sertraline, exacerbated his mental illness. Dr Chong gave knowledgeable evidence about his reasons for prescribing particular medications. He explained that he replaced sertraline with another antidepressant medication on 5 February 2020 due to Mr Mason feeling jittery, a possible side-effect. There is no evidence at all that sertraline cessation contributed to his deteriorating mental state, particularly given that he continued to be prescribed several medications for his depressive disorder and anxiety. These were present in his blood sample taken at autopsy.

57. I also do not accept the proposition that Mr Mason should have been admitted as a patient to the RHH on 12 February 2020, instead of being discharged from the Emergency Department. Mr Mason had the capacity to make his own decisions and had the support of his mother and sister. He was under Dr Chong’s regular care with the option to progress his mental health plan. Further, he did not avail himself of the offered support from the CAT team following his hospital presentation. This was not a case where an order under the Mental Health Act 2013 could have properly been made; and a lengthy hospital admission would not have reduced his suicidal ideation, particularly once he returned home and again commenced consuming alcohol in excessive quantities.

Circumstances surrounding death

58. On Saturday 15 February 2020 and Sunday 16 February 2020, Mr and Mrs Maguire travelled to Sydney leaving Mr Mason home alone. Ms Bishton visited him on Saturday 15 February with a quantity of beer. Mr Mason told his mother that he had been talking with Ms Gard who admitted to him that she had hurt her shoulder the day before he allegedly assaulted her and that she had attributed this injury to the assault in making the complaint. This disclosure caused Mr Mason further distress regarding what he perceived as the unfairness of the charges against him.

59. On Monday 17 February 2020, Mr and Mrs Maguire returned from Sydney. At about 3.00pm Mr Maguire noted that Mr Mason was intoxicated and observed that he continued to drink into the evening.

60. At approximately 7.50pm, Mr Maguire went to his caravan on the property and found that its back window had been forced open and two bottles of alcohol were missing.

He believed Mr Mason to be responsible. Mrs Maguire woke Mr Mason, who was sleeping in the armchair in the lounge and asked him if he had broken into the caravan and stolen alcohol. Mr Mason was instantly aggressive and argumentative. He allegedly pushed Mrs Maguire to her chest and took up a fighting stance with raised fists to Mr Maguire. A heated argument transpired during which Mr Mason entered the kitchen and threw kitchen items at Mrs Maguire. He then produced a knife from a kitchen drawer.

61. During this argument, at 7.56pm, Mrs Maguire made the initial 000 call. She could be heard swearing at Mr Mason and threatening to kill him. It was clearly a heated and confronting situation which I will describe in more detail further on. Mrs Maguire did not speak to or pass any details onto the 000 operator. However, the call provides significant insight into the heightened emotional state of those involved.

62. While Mrs Maguire was in the house with Mr Mason, Mr Maguire had gone outside to call police. Several 000 calls were made as follows.

63. At 7.59pm, Mr Maguire called 000 and stated that Mr Mason was “going off” in their house and he wanted him removed. The police Radio Dispatch Services (“RDS”) operator attempted to elicit details to identify Mr Mason.

64. At 8.03pm Mr Maguire again called 000, stated that Mr Mason was still “going off” but now had a knife. He said that Mr Mason was in the house but they were in their car at the top of the driveway. The operator advised that three police units (that is, three separate police vehicles) were heading their way. The operator then clarified with Mr Maguire that all persons were out of the house apart from Mr Mason.

65. The RDS operator made the following communication to potentially attending police units: “..are you heading to 233 Tea Tree Road um caller Wayne Maguire states his brotherin-law Geoffrey Mason is at the residence going off. I’ve had two calls on it. He couldn’t give me a date of birth although now we do have a Geoffrey Russell Mason born in ’81.

Uh he does have some cautions. Has threatened police with an axe previously and is diagnosed with hep C and there’s flagged offences with us. Copy.”

66. The November 12 police responding unit consisted of Constable Tim Mitchell as driver, Sergeant Brad Conyers as front seat passenger, and Constable Abu Chowdhury as rear seat passenger.

67. At 8.03pm November 12 departed Bridgewater Station. The vehicle was a fully marked police Subaru Outback wagon. A backup unit, November 75, had already been tasked and was at or around the Dromedary location heading towards Bridgewater.

68. At 8.05pm the following exchange occurred between Sergeant Conyers and the RDS operator whereby Sergeant Conyers requested a dedicated operator and confirmation of the address of the incident.

“Operator Roger. Just an update while I’ve got you one two and will pass this on to seven five with another operator the male has a knife. He’s inside the house although the occupants are outside copy.

BC Yeah one two copy that, if you could please assign an operator to this so the three of us can maintain contact with the caller just for their safety.

Operator Roger, Well do our best, um, one two. We’re getting smashed up here at the moment.

BC Copy that could you please pin post on the map and just give me a heads up where exactly the address is the exact location.”

69. At 8.09pm, November 12 arrived and took up an observation position across the road from 233 Tea Tree Road, awaiting backup units.

70. At 8.11pm, Mr Mason left the house with the keys to Ms Maguire’s grey Mitsubishi 380 sedan registered C96DM. He manoeuvred the vehicle in front of the residence, spinning the wheels on the gravel driveway before proceeding towards Tea Tree Road at speed.

71. The property, 233 Tea Tree Road Brighton, is in a flat semi-rural area situated on 1.1 hectares of land consisting of dry paddocks. The residence is a single-story dwelling with a 91.4-metre-long gravel driveway leading from Tea Tree Road to the front of the residence, providing the only access the property. The western boundary was marked by wire fencing topped with three wire strands supported by steel pickets and stood 1.2 metres high. The southern boundary fronting onto Tea Tree Road was fenced with a 2.1 metre tall vertical lapped paling fence supported by steel posts.

72. Whilst waiting across the road from the property, the officers in the November 12 unit reportedly heard screaming and smoke emanating from the residence which caused them to decide to enter the property to render assistance. They drove into the driveway and observed Mr Mason in the Mitsubishi heading towards them. On observing a child (XY) standing alone behind a Mitsubishi Outlander, they reversed and stopped at the driveway entrance, still with their emergency lights activated.

73. The incident escalated rapidly. Mr Mason rammed the Mitsubishi into the front of the police vehicle, pushing it rearward a distance of approximately 3.5 metres. Constable Mitchell was in the driver’s seat and applied the brakes. Mr Mason then reversed back down the driveway a distance of approximately 18 metres.

74. Constable Chowdhury exited the police vehicle and retrieved road spikes from the rear cargo compartment and deployed them across the gravel driveway approximately 5 metres in front of the Mitsubishi. He then returned in the direction of the police vehicle as Mr Mason again drove the Mitsubishi forward towards the police vehicle. Constable Chowdhury remained several metres to the passenger side of the Mitsubishi.

75. Sergeant Conyers also alighted from the front passenger side of the police vehicle and advanced forward with his firearm drawn, calling out to Mr Mason to stop and get out of his vehicle.

76. Constable Mitchell alighted from the driver’s seat of the vehicle and moved forward next to the driver’s side with his firearm drawn.

77. Mr Mason, driving the Mitsubishi forward, steered to the right, running over the road spikes with the passenger side tires. He accelerated forward towards Sergeant Conyers position. Sergeant Conyers continued calling on Mr Mason to stop. The right (driver’s side) wheels of the Mitsubishi left the gravel surface and drove onto the grass, with the direction of travel being towards Sergeant Conyers.

78. When Mr Mason was approximately 8-10 metres from Sergeant Conyers, Sergeant Conyers commenced firing at the vehicle and/or Mr Mason driving the vehicle. The issue of what Sergeant Conyers was aiming at is discussed later in this finding. Sergeant Conyers discharged 11 shots, all of which impacted the Mitsubishi but not Mr Mason.

79. At the same time, Constable Mitchell from his position on the other side of the Mitsubishi, also drew his firearm. He discharged five shots, two of which hit Mr Mason.

80. Constable Chowdhury did not draw his firearm.

81. During the shots, Mr Mason continued to drive forward, heavily impacting on the front left (passenger-side) of the police vehicle.

82. The police officers were wearing body-worn cameras and the footage showed that from the time Mr Mason initially rammed into the police vehicle until the last shot was fired, approximately 22 seconds elapsed.

83. It became apparent to the officers, upon the Mitsubishi stopping on impact with the police vehicle, that Mr Mason had been injured by one or more of the shots.

84. Despite the rapidly escalating incident, the officers had kept the RDS operator advised of the main developments at the scene. This included conveying that the potential offender was leaving the property, that he was ramming the police vehicle in the driveway, that shots had been fired, and that urgent ambulance assistance was required.

85. Then, at 8.12.50pm the officers advised RDS that Mr Mason had been shot at the scene and had sustained a head wound.

86. First aid was rendered to Mr Mason by the officers immediately while he was seated in the driver’s seat. He was then removed and placed on the ground behind the Mitsubishi where CPR was performed. Attending paramedics subsequently took over resuscitation but, after a short time, determined that Mr Mason was deceased.

87. Other police officers from the Bridgewater Station attended, assisted with CPR, gathered witness accounts and preserved the scene. Specialist police officers in the areas of ballistics, forensics, crash investigation and Professional Standards also attended the scene. As coroner on duty, I was called to attend and did so.

88. The investigation that followed culminated in a very detailed report to me by Sergeant Steve Herbert of Professional Standards (Internal Investigations). I have been greatly assisted by the factual contents of his report in this finding.

Mr Mason’s movements in the house and state of mind

89. The detailed sequence of events within the house leading to Mr Maguire calling the police is important in assessing Mr Mason’s state of mind and the level of fear he engendered in the Maguire family.

90. In considering what happened, I have particular regard to the frank and detailed accounts of Mr and Mrs Maguire in their police interviews and statutory declarations made shortly after the event in addition to their communications to the RDS operator. The evidence of Mrs Maguire at inquest was also helpful and consistent with her earlier accounts. Mr Maguire’s memory was, unfortunately, affected by the trauma of the incident.

91. Mr Mason was angry at the time when Mrs Maguire woke him from the armchair to ask whether he had taken alcohol from the caravan. In her statutory declaration, Ms Maguire said “he woke up quite pissed off. He basically said ‘I can’t believe you are accusing me of this.’” Ms Maguire further stated “Geoffrey started to get angry and said he was going to move out. I said, ‘fucking good job’ as I was sick of it.” An argument ensued whereby Mr Mason requested his rent money back. It was clear to both Mr and Mrs Maguire that Mr Mason was drunk.

92. Mrs Maguire, Mr Maguire and Mr Mason then started to walk towards Mr Mason’s bedroom. Mr Maguire said in his statutory declaration “Karen asked Geoffrey if we could have a look in his bedroom and see if he had taken alcohol from the caravan. At this time Geoffrey turned around and faced Karen, he gave her a slight push to the chest”.

93. Mr Mason blocked the door to his bedroom and Mrs Maguire retreated back in the direction of the lounge room. Mr Mason was yelling abuse at her from his bedroom, slamming doors before following her into the kitchen. It was at about this time that he raised his fist and went to hit Mr Maguire before following them back into the lounge room and kitchen area. He then picked up items from the kitchen bench and threw them at the doorway in which Mrs Maguire was standing. Mrs Maguire yelled at Mr Mason and then ran into her bedroom, calling for Mr Maguire to ring the police.

94. Whilst in her bedroom, Mrs Maguire could hear Mr Mason “yelling things whilst smashing items”. Mr Mason then entered the bedroom and attempted to pull the door off the runner. At this time Mrs Maguire and XY were sheltering in her bedroom ensuite and heard Mr Mason come into the bedroom. She approached him, spoke to him and then

witnessed him trying to pull the door off the runner and breaking a piece of architrave from the door. At this time, Mr Maguire was outside calling the police.

95. Mr Mason abused Mrs Maguire and said to her words to the effect of “I can’t believe you called the cops on me”, to which she told him to get out of the house and not to come back.

96. Mrs Maguire then observed Mr Mason go to the kitchen and select one of the biggest knives from the kitchen drawer. In her interview with police, she said: “.. he undone the drawer and then he was rifling through picking which knife, I assume.

He picked up a couple of little ones, then he picked up the big knife and then he just walked off, so he was just holding it in his hand and then he walked off.”

97. Mrs Maguire yelled to Mr Maguire that Mr Mason had a knife. She then grabbed XY and they ran through the lounge room to get to the front door and outside. At the top of the driveway they all waited for the police.

98. The evidence indicates that Mr Mason remained inside after obtaining the knife from the kitchen. Although not witnessed, I find that he then went to his own bedroom and set fire to his mattress and/or the curtains.

99. Mr Maguire, who was outside first, saw a considerable amount of black smoke coming from Mr Mason’s bedroom window. He ran back to the house and, once in the bedroom, saw that the mattress was on fire. He said that he “reefed the mattress out the window” as it was just starting to “take off”. Mrs Maguire also assisted in extinguishing the fire.

100. It is plain that Mr Mason engendered in the Maguire family grave fear for their safety.

His mood remained angry and aggressive and, in his state of anger and intoxication, he was clearly unable to calm himself and remained highly irrational. Mrs Maguire gave compelling evidence that she had never previously threatened her brother or exhibited such a level of anger towards him. She believed that her words and actions on this occasion would have had a great impact upon his mental state.

101. Whilst not outlined in his statutory declaration or interview, Mr Maguire gave evidence at inquest that, during the incident, he believed that Mr Mason had made a comment relating to suicide. Mr Maguire told the court “I think it was when Karen said to move out,

that maybe that he said that he would go and kill himself then. …I’m pretty certain he did say that.” I cannot make a positive finding that Mr Mason did refer to suicide. Mr Maguire did not tell police that it occurred, but he may not have thought to do so at that time.

I certainly cannot discount that Mr Mason referred to suicide on one occasion.

However, the evidence indicates that Mr Mason did not make any statement specifically when arming himself with the knife or at any time subsequently about why he had the knife.

102. The high level of emotion displayed by both Mrs Maguire and Mr Mason during the events prior to the arrival of Police is evident in the recording of the initial telephone call to Police at 7.56pm. Mr Mason was obviously in a heightened state, and may have been experiencing feelings of suicidal ideation, on the evening of 17 February 2020.

Cause of death

103. Following autopsy, experienced forensic pathologist, Dr Donald Ritchey, reported that Mr Mason died of a gunshot wound of the left side of the neck. The injuries resulting from the gunshots included basal skull fracture, subarachnoid haemorrhage of the left cerebellar hemisphere, copious blood in the carotid sheath and within the upper and lower airways and lungs; and fracture of the right side of the mandible.

104. Dr Ritchey was of the opinion that this gunshot wound would have resulted in rapid death. He reported that Mr Mason had a second gunshot wound of the anterior right shoulder. He stated that the wound was oblong and atypical with features suggesting an intermediate target was impacted before the bullet impacted the right shoulder. He noted that a markedly deformed jacketed projectile was recovered from this wound that only penetrated the skin and subcutaneous tissue. It did not contribute to Mr Mason’s death.

105. Mr Mason’s post-mortem alcohol level of 0.233 grams/100ml of blood was very high.

Clinical signs or symptoms at this level of alcohol include loss of critical judgment, impairment of perception, disorientation, decreased sensory response and increased reaction time. As described by forensic scientist Neil McLachlan-Troup in his evidence at inquest, intoxication at this level may well induce an exaggerated emotional state such as feelings of fear or rage.

106. The presence of carboxyhaemoglobin and nicotine in Mr Mason’s blood is consistent with his history as a smoker.

107. The presence in his blood of therapeutic levels of amitriptyline, diazepam and paroxetine are consistent with the prescriptions issued by Dr Chong on the 15 November 2019, 5 December 2019 and 5 February 2020 respectively.

108. In both his interview and evidence at the inquest, a friend of Mr Mason, Joseph Jones, stated that he had observed Mr Mason to use both cannabis and methylamphetamine (“ice”) in his presence. However, the toxicology results do not indicate Mr Mason was under the influence of either of those drugs at the time of his death; but substances are likely to have contributed adversely to his mental state over the years.

109. Mr Mason’s high level of intoxication at the time of the incident is likely to have been amplified by the other drugs in his system, and contributed to an impaired thinking process, impulsivity and an exaggerated emotional state. Nevertheless, the evidence of Mr and Mrs Maguire and Ms Bishton indicates that in the days leading up to the incident, Mr Mason had the capacity to make his own decisions and he was not affected by an altered mental state, such as psychotic or delusional thinking.

Issues at Inquest Information available to attending officers

110. The attending officers were provided with information by the RDS operator before they entered the driveway of the property. This information can be summarised as follows:

(i) Wayne Maguire of 233 Tea Tree Road had stated that his brother-in-law was going off; (ii) The brother-in-law was armed with a knife; (iii) The brother-in-law was inside the house; (iv) The occupants of the house were outside;

(v) The brother-in-law was most likely Geoffrey Russel Mason born in 1981; (vi) There were cautions and flagged offences on the system; (vii) Mr Mason had previously threatened police with an axe; and (viii) Mr Mason was hepatitis C positive.

111. In his interview, Sergeant Conyers explained that, upon receipt of the above pieces of information, his concerns were raised regarding the level of threat to those persons in the property and attending police. His initial decision to remain off the property in the vehicle until backup arrived was sound in these circumstances. His request for a dedicated operator to maintain contact with the caller from the property reflects his increasing concerns.

112. Upon questioning, Sergeant Conyers said that he would have welcomed a dedicated operator to “drill down” on previous incidents involving Mr Mason but explained that it was usual, particularly in the Bridgewater Division, to attend high-risk matters with people having extensive histories of violence. He explained that, on the day of the incident involving Mr Mason, he had attended four high-risk jobs. Sergeant Conyers recognised, however, that the reality of the situation was that resourcing would normally prevent this occurring.

113. In his report, Sergeant Herbert said that it was to the credit of Sergeant Conyers that he made attempts to seek real-time information from the caller in order to inform the response. I fully agree with that statement.

114. Further, Sergeant Herbert reported as follows:

• As of 17 February 2020 Tasmania Police had transitioned to a new intelligence and information system called ATLAS. This system was not as user-friendly as the systems it replaced and accessing information could be problematic.

ATLAS requires users to drill down and open multiple screens to find details such as intelligence and incident reports.

• Mainland convictions are not recorded on ATLAS. This information requires searching on another database.

• RDS was not able to provide information regarding further matters that may have increased the risks associated with this situation and potentially change the operational response. These included Mr Mason’s propensity for violence, history of being affected by alcohol and/or drugs, history of mental illness and history of self-harm.

• Had the RDS been able to provide any such additional information, as well as real time information from the occupants of 233 Tea Tree Road, it is possible

that further risk factors associated with Mr Mason may have changed the police response.

115. In summary, the officers faced a situation where the pertinent information available to them, including their own observations, was:

• The information provided by RDS as described above;

• That other persons at the property were potentially in immediate danger;

• That a significant fire appeared to be emanating from the residence but there was no information as to how it started; and

• Screaming could be heard coming from the residence.

116. It appears to me that communication in real-time with the caller, primarily Mr Maguire, would have been of assistance in informing the method of police response. This may have given further information to the attending police officers of the actual location of Mr Mason and all other persons on the property, as well as the source of the fire.

117. The officers responded to the events as they observed them unfold. Whilst further information may have been of assistance, it is unlikely to have affected the operational response in this rapidly evolving situation. Further information from the caller is likely to have reinforced the decision of the officers to enter the property when they did and take exactly the actions that they did.

118. The ATLAS system was new and somewhat unfamiliar at the time in question. It is possible that RDS may have been able to interrogate the system further if not for its high workload. ATLAS was also available to Sergeant Conyers to access in the vehicle using his iPad tablet. However, at that time, his tablet battery was flat (being at the end of his shift) and there was no time available to do so.

119. Counsel for Ms Bishton specifically submitted that there was no information passed to the police by RDS that Mr Mason had a 2019 drink driving offence and that he did not currently have a licence. Counsel submitted that full details of Mr Mason’s history were not known by attending police; that the affray charge, for which he had been jailed in Melbourne, was more than 10 years old; that he had planned on pleading not guilty to allegations of common assault against Ms Gard; and the full extent of his prior matters of violence.

120. As Sergeant Conyers said at interview, more detailed information being provided by the RDS about these matters would have assisted the decisions of the attending officers.

However, given the developments directly observed by the officers while observing 233 Tea Tree Road, it seems unlikely that more detail about Mr Mason’s previous interactions with police would have altered Sergeant Conyers’ decision to take emergency action and enter 233 Tea Tree Road.

121. I agree with the submissions of Ms Bishton’s counsel that the provision of all available information in a timely manner is of critical importance and can only enhance decisionmaking of officers responding to incidents.

122. The ability of RDS to quickly access intelligence and convey it to responding officers should be continued to be evaluated by Tasmania Police.

The form-up point and decision to enter the property

123. In his interview Sergeant Conyers stated in relation to the choice of the initial form-up point on Tea Tree Road opposite the property: “….so I asked RDS to get them (New Norfolk Unit 75) onto the channel that I’d asked for um, so we, we then proceeded reasonably slowly up the exit to Tea Tree Road and it was then, as I was, as we were in that exit that I realised that the address that we were talking about was right in front of the exit which um, provided a bit of a challenge because I, I’d not perceived that previously but then when we approached the exit it was clear that there was a large fence there that had afforded us some visual cover so at that point I was satisfied that um, we could appropriately form up close by to that and still have some tactical advantage. So I identified to Tim the gravel verge that was immediately left on Tea Tree Road adjacent to the property and asked him to park there.”

124. It is clear from the evidence that Sergeant Conyers intended to meet with the requested backup unit at a rendezvous or form-up point, in order to discuss and plan the operational response.

125. After explaining his belief that the New Norfolk Unit was at least five minutes away, Sergeant Conyers further explained:

“So at that point my intention was to keep observations on the driveway of the property and wait for assistance and then at that time also I was still looking at this property on my phone trying to picture where I would deploy resources to contain the scene and I was sort of picturing that I would have in the initial stages five people and two police cars because we were three up.”

126. At 8.07pm, November 12 arrived at the form-up point, which was a good choice of location in the circumstances. They were stationary at that point for approximately three minutes when the situation changed dramatically. Sergeant Conyers said at interview: “Tim alerted me to the smoke coming from the property um, I looked at the fence which was high enough that the only thing I could see was the roof, the, almost the entire roof coming from the property and when I looked I saw a significant amount of black smoke that was emanating from the right corner of the property and I also heard a scream a female voice scream…. I can’t remember the words I used to Tim but I told him to go, to get, drive in, um he drove 50, 75 metres or so from our position to the driveway turn right onto the driveway and started to drive down the driveway”

127. Constable Mitchell saw black smoke and flames coming out of the right side of the building and around the eave-line in an increasing amount. He also heard screaming and said to Sergeant Conyers that they needed to go in. At interview, he described the situation as having escalated to a point where emergency action was required to render assistance.

128. Similarly, Constable Chowdhury confirmed that, whilst they were awaiting backup units, there was increasing smoke emanating from the house and that “..kids were screaming and people were screaming in the house.”

129. In their interviews, as well as in evidence at the inquest, all three officers reiterated that the decision to enter the property prior to the arrival of the backup unit was based on their combined observations of what they saw and heard at 233 Tea Tree Road from the form-up point. These observations were against the backdrop of the information provided by RDS, particularly that Mr Mason was armed with a knife and there were other people present at the address.

130. The circumstances involved what appeared to be a serious threat to the occupants. The officers could not have done otherwise but to enter the property. It is to their credit that they did so without hesitation and without waiting for backup.

131. The legal basis for the entry to 233 Tea Tree Road is also without controversy. Police were invited onto the property by the occupant, Mr Maguire, who had requested their attendance to remove Mr Mason. They therefore entered with the owner’s consent.

Further, it was lawful for the officers to enter the property and arrest a person without warrant whom they had reasonable grounds to believe had committed a crime: Criminal Code section 27A and section 27. It was reasonable that the officers held a belief that Mr Mason had at least committed the crimes of assault and arson. Their power of arrest without warrant extended to a person committing a breach of the peace.

132. The decision of Sergeant Conyers, Constable Mitchell or Constable Chowdhury to enter 233 Tea Tree Road was lawful, necessary, consistent with their training, and responsive to a rapidly developing and dynamic situation that required an emergency response.

The activation of body-worn cameras

133. The staged rollout of the body-worn cameras commenced in August 2018 and was completed by December 2019 for all mainland Tasmanian police stations. Therefore, on 17 February 2020, the date of Mr Mason’s death, the use of body-worn cameras by police was a recent requirement.

134. The use of body-worn cameras is covered by s.10(10) of the Tasmanian Police Manual (“TPM”) which includes the following provision: “Members shall commence body-worn camera recordings prior to, and during, any situation where a member exercises a legislated or common law police power in performance of their duty, unless a genuine reason exists for not doing so.”

135. As at 17 February 2020, Tasmania Police used the Axon Body 2 camera. Relevantly, its features included: (i) a12 hour plus battery; (ii) a 143-degree diagonal field of view lens; and (iii) 30 second pre-event buffering.

136. The 30 second pre-event buffering function means that, while the body-worn camera is switched on, it will continually capture a 30 second loop of video that refreshes every

30 seconds. When the body-worn camera is activated, it saves or back-captures 30 seconds of video and commences recording from that time. The 30 second buffering works only when the body-worn camera is switched on. The back-capture does not contain audio.

137. Sergeant Conyers, Constable Mitchell and Constable Chowdhury were all wearing body-worn cameras when they entered 233 Tea Tree Road. All three acknowledged that they had been trained in the use of body-worn cameras and needed to comply with the order set out in 10(10) of the TPM.

138. The footage from the camera of Constable Chowdhury commences as he gets out of the rear driver’s side of the police vehicle to retrieve the road spikes from the boot. It shows both Sergeant Conyers and Constable Mitchell discharging their firearms when Mr Mason drives in the direction of Sergeant Conyers. At that time Constable Chowdhury’s position is behind Constable Mitchell. There is no sound until Sergeant Conyers fires his final shot into the front left tyre of Mr Mason’s vehicle.

139. Sergeant Conyers’ footage begins when he gets out of the police vehicle, after it has already been rammed by Mr Mason. It covers him moving forward towards Mr Mason’s vehicle with his firearm drawn, Mr Mason appearing to drive in his direction, and his own discharging of his firearm. There is no sound until after Mr Mason has been shot by Constable Mitchell.

140. Senior Constable Mitchell’s body-worn camera footage does not commence until after all shots had been fired. Constable Mitchell can be seen removing Mr Mason from his vehicle, and all three officers can be seen rendering medical assistance to him.

141. In both his interview and evidence at the inquest, Constable Mitchell explained the reasons for his body camera not being activated during the actual shooting. At his interview, he said: “I have activated that um, or attempt to activate it immediately after I had discharged the firearm. So after entering the driveway um, but as I alluded to in our preparation prior to leaving the station we were literally about to cease duty. I’d removed the majority of my accoutrements including the body-worn camera and had switched that off um, and then basically we were in the vehicle and proceeding quickly and urgently in the end, to um the incident and my focus during that was on driving safety and basically

listening to all of the information that was being provided to us as well as attempting to figure out exactly where the address was.”

142. Constable Mitchell said at interview that as soon as he discharged his firearm and reholstered it, he took steps to activate his camera. This is confirmed by the footage.

143. Sergeant Conyers said at interview, and confirmed in evidence, that he did not have a specific recollection of turning on his body-worn camera. He stated: “…body-worn cameras are new and there is a period, certainly for myself, having worked, you know, eighteen years without them and really to be honest not receiving any practical training or practice on, at, you know, putting them on at certain circumstances it’s more on the job and it’s just, and I’ve certainly identified times where, oh gee I’ve forgot um, and my answer to that is, I had so many things go through my mind at the time, trying to plan things and once again, I think me not putting it on would further show that it was never my intention to go in at that time.”

144. Sergeant Conyers said that his intention was to have a briefing with attending police, including backup units, at the form-up point before entering the property; and that he anticipated that part of that briefing process would involve him instructing all officers to turn on their body-worn cameras before entering. He said that the escalation of events, requiring an emergency response, prevented that occurring.

145. Sergeant Herbert described the failure of the officers to turn on body-worn cameras at an earlier point as a “source of frustration for the investigation”.

146. Had each of the officers turned their cameras on at the proposed rendezvous point, it is highly likely that there would have been sound at the critical time and more comprehensive footage from different angles would have been obtained.

147. Sergeant Conyers had received some training in the operation of body-worn cameras by 17 February 2020. Perhaps, he did not receive a significant amount of practical training. Nevertheless, I am confident that he would have averted to the need to ensure that the officers had activated them as part of his briefing once the backup team had arrived. If that had that briefing occurred, Constable Mitchell would also have detected that his camera was actually turned off.

148. In the circumstances confronting the officers, it is entirely understandable why their cameras were not activated at the form-point prior to the decision being taken to enter the property. The urgency of the situation provides a clear and reasonable basis to explain why each officers’ cameras were activated at later times.

149. I also fully accept that the rapid escalation of events constituted a genuine reason for the officers not activating their cameras promptly. This is particularly the case given their very recent introduction and that the activation had not perhaps become automatic at that time. Fortunately, each officer did manage to turn their camera on, and the central events surrounding the shooting of Mr Mason have been recorded.

150. In all the circumstances, there can be no legitimate criticism of the officers. Further, my comment upon this issue is not one causally connected to the death but one which relates to the capturing of vital evidence.

151. In conclusion, the use of body-worn cameras was a very recent requirement by Tasmania Police as at 17 February 2020. The activation of body-worn cameras is now a routine process for responding police officers.

152. Education on the use of body-worn cameras is included in the training of officers at the Police Academy. All officers must complete the training and obtain a licence to use the device. The training comprises four modules and includes a demonstration of the characteristics of the device and the way that they are operated.

153. There was no suggestion at inquest that the current training is not sufficient or satisfactory. My own experience is that body-worn camera footage from attending officers is helpfully available in respect of almost all coronial scenes where footage is required to be captured.

The decision to block the driveway with the police vehicle

154. Although the officers entered initially into the driveway, they observed Mr Mason in a vehicle further up the driveway, apparently with a knife. They also saw XY standing alone behind the Mitsubishi Outlander parked further down the driveway close to the road. It appeared to Sergeant Conyers that a serious crime may have been committed and that Mr Mason’s movements were that of a person fleeing the scene.

155. It was the intention of Sergeant Conyers to arrest Mr Mason for common assault based upon the information received up to that point. It was also his intention to ensure that he did not leave the property, which would involve putting other road users at risk.

Sergeant Conyers therefore instructed Constable Mitchell to block in Mr Mason.

Constable Mitchell reversed the police vehicle so that it occupied most of the driveway entrance. Sergeant Conyers’ intended strategy at this point was to contain Mr Mason and to negotiate.

156. I observe that the police vehicle situated at the entrance of the driveway constituted a “roadblock” and was governed by the provisions of the Police Powers (Vehicle Interception) Act 2000. In particular, the requirements of section 5 of that Act were fulfilled. The roadblock was in place to protect others in a situation where there was a reasonable belief that the safety and lives of others were endangered; and to significantly improve the prospects of apprehending Mr Mason.

157. The decision to block the entrance was made deliberately and rationally upon the information at hand and was not in itself an aggressive action. It also placed the officers in a good position for negotiation and arrest, as well as ensuring that Mr Mason could not move, or move easily, out of the property.

158. The TPM further requires officers not to use a police vehicle as a roadblock unless set exceptional circumstances exist. For the reasons referred to, exceptional circumstances were clearly present in this case.

The deploying of road spikes

159. After blocking the driveway and having been rammed by Mr Mason, Sergeant Conyers instructed Constable Chowdhury to deploy the road spikes. This was in accordance with his intention to contain and apprehend him.

160. The use of road spikes, being a vehicle immobilising device, is also governed by the Police Powers (Vehicle Interception) Act 2000. There was no issue in this inquest that the decision to deploy road spikes was a decision which was sound and lawful. Both Constable Chowdhury and Sergeant Conyers were validated in the use of such devices. Constable Chowdhury deployed them in accordance with the direction of Sergeant Conyers, in compliance with section 6 of that Act.

161. Further, in accordance with section 5 of that Act, Sergeant Conyers formed a reasonable belief that deploying the road spikes would significantly improve the prospects of apprehending Mr Mason and was necessary for the protection of life or property.

162. It must be appreciated that Sergeant Conyers was required to make the decision, and Constable Chowdhury to execute it, in a matter of seconds. Mr Mason had already rammed the police vehicle, had reversed back down the driveway and had commenced to accelerate again apparently in preparation for ramming the police vehicle a second time.

163. At interview, Sergeant Conyers states: “The car accelerated heavily towards us and straightened and I told Tim to block, it my words I believe were block it. And by that I mean block access to the property and I also said to… I’m not sure who I said this to, I actually just said spikes. Um obviously it was going to be Abu who was sitting in the back. Um, and my, my, I thought he would be sitting with the spikes in the back seat… that’s the way we set our cars up”.

164. As seen in the footage, Constable Chowdhury retrieved the road spikes quickly from the boot of the police vehicle once Mr Mason reversed away after the initial ram. He deployed the road spikes in front of Mr Mason’s vehicle by casting them across the majority of the width of the driveway. It was less than two seconds after deployment of the spikes before Mr Mason accelerated over the spiked area of the driveway. Constable Chowdhury placed himself in danger in order to deploy the spikes.

Sergeant Conyers decision to draw his firearm

165. In his report, Sergeant Herbert outlined the requirements for police officers to use lethal force. In summary, police officers are vested with lawful authority to use force in self-defence, in the defence of others and to protect the public welfare. He outlined the requirement that in the extreme cases where a firearm is used to protect life, it should be used to incapacitate the subject immediately. Therefore, police officers are trained to shoot at the greater body mass of the subject. If any other target area is identified, there is greater scope for the officer to miss that target and endanger other persons who may be in the immediate area.

166. The TPM outlines that officers should not fire their firearm at or from a moving vehicle.

Sergeant Herbert also outlined the principles in relation to discharging a firearm emphasising that a firearm should not be used when less extreme means are sufficient to achieve the safety objective.

167. The TPM requires various things to occur in situations where police officers are warranted in using firearms. The officer should, if possible, give a clear verbal warning of their intent to use firearms and ensure there is sufficient time for the warning to be acted upon before using the firearm. The evidence indicates that Sergeant Conyers was fully aware of the principles governing the use of force, including lethal force.

168. Sergeant Conyers maintained at interview that the drawing of, and discharge of, his firearm was necessary in self-defence because Mr Mason was driving the vehicle at him and intended to run him down. He said that he believed he would be killed and reiterated his belief in his evidence at inquest. He said at interview “this is it, this is how it happens, just had nowhere to go…” He described the conflict in his mind during the seconds that Mason was reversing in preparation to move forward. His thoughts were occupied about whether he would need to shoot and whether, in the circumstances, it was safe to do so.

169. In his evidence at inquest Sergeant Conyers stated that after the initial ramming, he felt that he and the other officers were under imminent threat. Sergeant Conyers believed that had he remained in the police vehicle, which Mr Mason continued to ram with his forward momentum, he would have potentially become disorientated to the point where he would have been prone to an attack by Mr Mason who was armed with a knife.

170. Sergeant Conyers therefore alighted from the front passenger side of the police vehicle.

The footage shows that the front of Mr Mason’s vehicle remained in contact with the front of the police vehicle. Sergeant Conyers initially sheltered near the rear passenger door. As Mr Mason reversed away from the police car, Sergeant Conyers moved forward, drew his firearm, and pointed it in the direction of Mr Mason. At that point, Sergeant Conyers was in front of the bonnet of the police vehicle and to its left.

171. At inquest, Sergeant Conyers gave evidence that when the car veered in his direction and accelerated, he thought “this is it”. He explained that he meant he thought he may be killed. He explained that he was in no doubt that the vehicle was being driven at him.

172. In deciding to use his firearm, Sergeant Conyers explained his reasoning: “I might actually have to fire at him and the overwhelming memory that I have is that the ballistics was that there was a house there was other people there were kids and that I had cause for concern straightaway about that but I did not get a lot of time to reassess because he reversed probably 15 metres and then just put the car in back into gear and accelerated heavily towards me from that point until shortly after the second collision my memory is sort of in pictures rather than movie if that makes sense. It’s thoughts and pictures as opposed to a video”.

173. Sergeant Conyers was not cross-examined regarding his belief or reasoning at the time he fired his weapon.

174. I found Sergeant Conyers at all times presented as an honest and truthful witness. He did not deviate from his evidence in any significant way. The evidence given by him was consistent in all material respects with the evidence given by him during his police interview. Significantly, his evidence was wholly consistent with the body-worn camera footage.

175. I note that Sergeant Conyers had not seen and was not shown the body-worn camera footage until the latter stages of his interview and only after he had given his substantive account. He did not change his evidence in any significant way after viewing the footage.

176. The evidence makes clear that Sergeant Conyers’ decision to fire was made independently of, but almost simultaneously with, the decision of Constable Mitchell to fire. This is consistent with the serious level of the threat presented by the actions of Mr Mason towards Sergeant Conyers.

177. The immediate threat posed by Mr Mason to Sergeant Conyers and others at the scene was of a very high level. Mr Mason was not receptive to any attempts by the officers to apprehend him, was not rational in his state of mind, and was using the vehicle as a weapon. I have viewed the footage many times. I am satisfied that Mr Mason had ample time to see Sergeant Conyers in front of him with his weapon drawn and to stop the vehicle before accelerating forward. I am satisfied that, upon moving forward, he did see Sergeant Conyers close to him and standing alone, and he deviated towards where Sergeant Conyers was standing. I accept Sergeant Conyers’ evidence that Mr Mason made eye contact with him during this time and gave no indication that he would stop his vehicle.

178. It can never be known whether Mr Mason’s actual intention in deviating was to run down Sergeant Conyers, or tentatively to avoid the road spikes and attempt to leave the property via the narrow gap between the police vehicle and the boundary fence on the western side of the property. However, if his intention was the latter, Mr Mason could have left the property by driving through the wire fence at a point higher up in the driveway and travelling over the neighbouring property onto the road.

179. I find that at all times when Sergeant Conyers fired his weapon, he held a reasonable belief that he or other persons were in imminent threat of death or serious injury. The discharge of his firearm was necessary and no other less than lethal force option was available to him.

180. At a further point, I will deal with whether Sergeant Conyers intended to fire at the vehicle or at Mr Mason and the fact that he was not validated at that time to use his firearm (a fact of which he was unaware).

The decision of Constable Mitchell to fire at Mr Mason

181. Constable Mitchell, like Sergeant Conyers, gave evidence in his interview and at inquest regarding his state of mind at the time he decided to fire his weapon. He maintained at all times that he believed there was an imminent threat to the life of Sergeant Conyers as well as the other persons present.

182. Inspector Philippa Burk at Bridgewater Station spoke to Constable Mitchell immediately after the event and recorded what he said had happened. Her notes of the conversation state: “vehicle driven towards Brad, Tim thought Brad was going to die and he didn’t believe Mr Mason would stop as a result of Sergeant Conyers shots.”

183. As was the case with Sergeant Conyers, Constable Mitchell was not challenged by any counsel regarding his state of mind and beliefs at the times he fired his weapon.

184. For example, it was never put directly to Constable Mitchell that the force used by him in firing at Mr Mason was disproportionate to the threat posed to Sergeant Conyers, himself or the others in the yard.

185. Constable Mitchell at all times presented as an honest, intelligent and credible witness. He did not deviate from his evidence in any significant way. The evidence

given by him was consistent in all material respects with the evidence given by him during his police interview.

186. Significantly, his evidence was also wholly consistent with the body-worn camera footage. Constable Mitchell had not seen, and was not shown, the footage until the latter stages of his interview and after he had given his substantive account. He did not change his evidence in any significant way after viewing the footage.

187. Constable Mitchell and Sergeant Conyers both stated that they made the decision to fire their weapons independently of each other. This is likely to be the case because of the obvious and immediate threat to Sergeant Conyers when Mr Mason deviated towards him in the vehicle. Such a threat could not be mitigated by any other action.

188. I note particularly that Mr Maguire, in his police interview, was definite that Mr Mason posed a threat to the police officers by his manner of driving. Mr Maguire further said that he did not believe there was anywhere for the officers to move out of the way and that they were in danger. Finally, he said at interview that he believed “something serious” was going to happen and that they had to take their actions for their own safety.

189. I am satisfied that Mr Maguire, who witnessed the event, genuinely held these beliefs and that he was correct in his assessment of the circumstances. Although his evidence at inquest departed from this view, I prefer his forthright account to police when the event was fresh in his mind.

190. Counsel assisting and counsel for the officers emphasised that the entire incident occurred in a matter of seconds and Constable Mitchell had no time for either calm or detailed reflection.

191. I was referred by counsel to the comments of Connor J in Macintosh v Webster (1980) FLR 112 at 123: “[arrests] are frequently made in circumstances of excitement, turmoil and panic and it is altogether unfair to the police force as a whole to sit back in a comparative calm and leisurely atmosphere of the Court room and make minute retrospective criticisms of what a police officer might or might not have done or believed in the circumstances”.

192. This passage was adopted by the New South Wales Court of Appeal in Woodley v Boyd [2001] NSWCA 35 at 37. In that decision, Hayden JA also said at 38; “And, in evaluating the police conduct, the matter must be judged by reference to the pressure of events and the agony of the moment, not by reference to hindsight”.

193. Counsel for Ms Bishton, Ms Graves, submitted that Constable Mitchell should have had a clear view of Sergeant Conyers and thus known that he was not in imminent danger. She also submitted that Mr Mason was driving his vehicle toward a gap in the fence and not towards Sergeant Conyers. Finally, she submitted that Constable Mitchell’s fatal shot was discharged at a time when the danger to Sergeant Conyers had passed.

194. I have had regard to these detailed submissions. However, I do not consider that they have validity in the circumstances. I fully accept the evidence of Constable Mitchell that he did not see Sergeant Conyers. It is possible that he may have been able to do so but did not because of his need to concentrate upon Mr Mason. His shots were discharged in such rapid succession that it is unrealistic to find that he should have stopped shooting at the time when Mr Mason’s vehicle passed Sergeant Conyers. I also agree with counsel for the officers that the footage does not inform to any reliable extent what Constable Mitchell may or may not have seen. Constable Mitchell himself said that he was focused on the driver and did not have sight of Sergeant Conyers when he began discharging his firearm until after he had fired his last shot. Significantly, the body-worn camera footage of Constable Chowdhury shows that when Constable Mitchell commenced firing, his eyes were focused on the vehicle and not on Sergeant Conyers.

195. I also find upon the evidence that the vehicle continued with its forward momentum after the initial impact with the police vehicle and after the fatal shot was fired.

Constable Mitchell, not having sighted Sergeant Conyers, thought it possible that he may have been under or dragged by the vehicle; and that at the time he fired the final shot there was a potential ongoing risk of Mr Mason reversing and continuing to pose a threat to everyone in the yard.

196. The footage graphically illustrates the speed with which the incident transpired. I accept the submission of counsel for the officers, in accordance with the authorities,

that great caution should be exercised before making critical comments in hindsight concerning police action.

197. This caution should be applied to the timing of Constable Mitchell’s fifth and final shot which caused the fatal injury to Mr Mason.

198. In his affidavit, ballistics expert Sergeant Gerard Dutton provided evidence about the fifth shot as follows: “An examination of Constable Chowdhury’s body-worn footage shows the fatal bullet impact to Mr Mason must have occurred immediately following the heavy impact of the two vehicles with the unrestrained driver flung forward from his seat. The driver’s head and upper body can be seen momentarily in a pronounced forward position immediately after the collision as energy transfer between the vehicles was taking place and before the cars rebounded through the driver’s back into his seat. If the pistol discharged by Constable Mitchell had not occurred at the moment of the collision and the driver normally seated it is my opinion it is highly unlikely that the bullet would have struck Mr Mason.

199. At interview, Constable Mitchell also indicated that he believed others were in potential danger from Mr Mason’s actions.

“I perceived it to be an imminent threat to Sergeant Conyers but it sounds weird but as I perceived it to be a threat to everybody in the yard at that stage. Or the vehicle was in motion I believe if the actions that we hadn’t taken weren’t taken then it would either be Sergeant Conyers who had been killed by the vehicle or if he had been left to drive around the yard he would have killed either myself or Constable Chowdhury or other members within that yard… It was my only force option in that circumstance. There was no like we’d used our presence we’d tried to communicate with him we’d tried to use guidance with our hands there was I know Constable Chowdhury had attempted to use road spikes to immobilise the vehicle there was nothing left in our toolkit.”

200. On the totality of the evidence, the actions of Constable Mitchell were both lawful and proportionate. When Constable Mitchell fired his weapon, he held a reasonable belief that Sergeant Conyers was in imminent threat of death or serious injury and that the use of lethal force by him was not unreasonable in the circumstances as he believed them to be.

The number of shots fired by Sergeant Conyers and Constable Mitchell and their points of impact

201. Evidence on this matter came from Sergeant Gerard Dutton. He is a highly experienced and highly regarded forensic firearms investigator and I have no hesitation in accepting his clear and detailed evidence regarding the sequence and trajectory of the fired shots.

202. Sergeant Dutton was involved in this investigation in the following manner:

(i) He examined the scene at 233 Tea Tree Road soon after the incident; (ii) He examined the firearms used by Sergeant Conyers and Constable Mitchell; (iii) He recovered fired cartridge cases and bullet fragments from 233 Tea Tree Road; (iv) He attended the autopsy of Mr Mason and examined Mr Mason’s injuries;

(v) He examined the Mitsubishi driven by Mr Mason at the examination bay of Forensic Services, where he documented and photographed the bullet damage; (vi) He conducted laboratory and comparative microscopic examinations of the recovered fired cartridge cases and bullet fragments; (vii) He provided a detailed affidavit containing his findings; and (viii) He gave expert evidence at inquest.

203. Based upon the clear and helpful evidence of Sergeant Dutton, I find that 11 cartridges were discharged by Sergeant Conyers. All except the last two hit the right (driver’s side) of the vehicle at low height. None impacted Mr Mason.

204. There were 5 cartridges discharged by Constable Mitchell. Both the first and second discharges were in close succession from a similar position in front of, and to the left side of the car. It was not possible to determine the order of the discharges.

205. The third discharge impacted with the front left door pillar fired from the left side of the vehicle or approximately level with the front left tyre.

206. The fourth discharge impacted with the front left passenger window and central console. Sergeant Dutton said that the physical evidence indicated that it is far more likely the bullet broke the front left window and struck the left side of the centre console moments before the fatal bullet was fired.

207. The fifth bullet Impacted with Mr Mason’s head and the inside front right door pillar.

The front left window was shattered and only partially collapsed when the fatal bullet entered through the same windscreen frame impacted by the fourth discharge.

Did Sergeant Conyers fire at the vehicle driven by Mr Mason rather than Mr Mason himself?

208. Police officers are vested with lawful authority to use force in self-defence, defence of others and to protect the public welfare. There is a public expectation that police are confident and competent in the use of their firearms.

209. In the few cases where a firearm must be used to protect life, it is necessary to incapacitate the subject immediately. Thus, police officers are trained to shoot at the greater body mass of a subject. Such action at the very least would be expected to cause grievous bodily harm. However, it is also a large area which will, when hit, debilitate the subject and yet provide a chance of survival. Aiming at the body mass is also a larger target area where the shot may remain within the body. Therefore, by shooting at the body mass, there is less chance of the bullet endangering other persons in the vicinity.

210. The TPM, section 10.8.5b, outlines that a member should not fire their firearm at, or from, a moving vehicle.

211. Counsel for the officers, in submissions, made the point that the word should is not mandatory and, in any event, the facts before the court justified Sergeant Conyers shooting at a moving vehicle. Counsel submitted that the wording is unsatisfactorily ambiguous and consideration ought to be given by Tasmania Police to implementing an appropriate “hostile vehicles” policy which would specifically permit an officer to discharge their firearm at a moving vehicle in situations where they fear death or grievous bodily harm to any person.

212. Sergeant Conyers said at interview that he was aiming at “essentially the corridor or silhouette of the seat and anything in that line to the low side of it.” He said that he intended to shoot Geoffrey Mason.

213. In both his interview and evidence, Sergeant Conyers consistently maintained that his intention was to stop Mr Mason by shooting at him. He stated that the initial shots were low because he was conscious of the danger his actions posed to others. He further

stated that it was a dynamic situation, with a rapidly moving target, where it was difficult to gauge the fall of the shots. He agreed the last shot was deliberately fired into the front left tyre. He gave evidence that he had a recollection of firing the first group of shots and the last shot but did not have a specific recollection of the shots in-between.

214. It is clear from the evidence of Sergeant Conyers, as already dealt with, that he was very conscious of the position of other persons on the property at the time he commenced discharging his firearm. He was, for example, aware of XY’s presence and position at the time of entering the property, stating “I looked to the right of the police vehicle and saw a child a male child at that time, I actually have a six year-old son and I just thought that’s be like, he is the same as my young bloke.”

215. He recalled commencing firing by shooting low. He stated “I fired the first shot I don’t know at what point how far away he was I’m not sure but I just remember not being able to see a full shot I remember sort of shooting sort of instinctively sort of lower level to high just because I didn’t want to start high wanted to shoot over the target… at the time I lost all sound I could not hear anything at all, I couldn’t hear my firearm and that so much so that I have haven’t been I actually have like a picture of looking at the slide because at that point like I think I was well I know it was all instinct aiming like it wasn’t any site picture it was just instinct because I could not see where the shots were going”.

216. In his evidence at the inquest, Sergeant Conyers said that he was not conscious of the positions of Constable Chowdhury at the time of firing. He could recall Constable Mitchell had his firearm drawn and glass shattering.

217. Sergeant Herbert, in his report, formed the opinion that Sergeant Conyers was not shooting at the body mass of Mr Mason as he should have done in accordance with his training. Before resolving that question, I must resolve a difference between the experts, Sergeant Dutton and First Class Constable Warrington, who expressed particular views on the question of where Sergeant Conyers was aiming when he discharged his weapon.

Opinion evidence of Sergeant Dutton and Constable Warrington

218. An issue arose as to what inferences could be drawn from the pattern of damage caused by the shots. In particular, was Sergeant Conyers aiming at Mr Mason’s vehicle (including tyres) or at Mr Mason himself?

219. Sergeant Dutton maintained in his evidence that he did not consider that Sergeant Conyers was firing at the driver, especially considering the way police are trained to shoot at that distance. He firmly maintained this position even when it was put to him that Sergeant Conyers may have been deliberately firing low but still intending to hit Mr Mason.

220. Focusing on the first two shots only, Sergeant Dutton said in evidence “….And I can’t imagine at that distance you would misalign your sight so badly that you’re aiming at the driver and hitting those locations. That makes no sense to me. I can’t comment on his ability as a pistol shooter but the difference being your sight picture for those two shots to where the driver is sitting is very different.”

221. Sergeant Dutton stated that his expert role involved recording what happened from the physical evidence. It was not his specific role to comment upon the shooter’s intention.

However, in analysing the particular pattern of shots with reference to a known target, I consider that Sergeant Dutton might well be in a position to provide useful comment upon a shooter’s intent, as he has done in this case.

222. Constable Rod Warrington is a very experienced operational skills trainer in Tasmania Police and has designed and delivered firearms training for police officers. Relevantly, Constable Warrington was also involved in the delivery of high-risk motor vehicle interception training implemented by Tasmania Police in 2018. That training is restricted to stationary vehicles. As noted above, the current policy as set out in the TPM is that officers should not shoot at moving vehicles.

223. Constable Warrington provided two affidavits to the inquest and gave oral testimony.

His second affidavit included an opinion based upon the body camera footage of all three officers. Unlike Sergeant Dutton, Constable Warrington’s evidence supported the proposition that while Sergeant Conyers’ intention was to aim at Mr Mason, multiple factors affecting his aim may have led to him shooting low and left.

224. Constable Warrington provided a number of reasons why a shooter in the position of Sergeant Conyers may have significantly reduced accuracy. These included the following:

• As the heart rate elevates in response to a threat, competence may degrade causing large movements of the index finger and hand. This, in

turn, leads to jerking of the trigger by the shooter. In right-handed shooters this results in shots travelling downwards from the aim point to the left.

• Angular firing in relation to a target will make aiming more difficult.

• A moving target adds further complication as the firer adjusts their aim and position to the target.

• Movement of the firer in any direction has the capacity to further degrade accuracy.

• Because of evidence of threat to life, police were forced to act at a tactical level. The ramming of the police vehicle constituted an urgent and serious threat of injury and death. This required action to save life from an active, as opposed to a static threat.

• Bystanders and police officers were in Sergeant Conyers’ potential line of fire as Mr Mason’s vehicle moved forward towards him.

225. This potentially explains the position of damage caused to the front right plastic panel and the third to the tenth shots to the right side of the vehicle. The eleventh and final shot to the front left tyre was intended to disable the vehicle which he understood to be a continuing threat.

226. In that context, counsel for the officers submitted that Sergeant Conyers’ evidence was firm and credible and, being direct and primary evidence of intention, should simply be accepted.

Conclusions regarding Sergeant Conyers’ shooting

227. I fully accept that Sergeant Conyers was aiming for the body mass of Mr Mason in the vehicle for at least the first two shots. At that time, Mr Mason was driving towards him.

It remains a reasonable hypothesis that Sergeant Conyers was aiming at Mr Mason inside the vehicle in respect of the next seven shots rather than at the vehicle itself. However, I think the best explanation for these low subsequent shots is that Sergeant Conyers either consciously or unconsciously dropped his aim to take into account the safety to the people on the other side of the vehicle. By that stage, Mr Mason had driven past him and the threat to himself was, at least temporarily, gone. This fact may well have influenced his aim.

228. Sergeant Conyers was justified in shooting at Mr Mason in order to defend himself and others. Mr Mason was using his vehicle as a weapon. In these circumstances, he should not be criticised for lowering his aim on his subsequent shots to protect those civilians and officers at risk from the discharge of his firearm.

229. Relevantly, changes to the TPM outlined in the affidavits of Assistant Commissioner Glenn Keating, were made on 4 July 2023.

230. These are as follows:

(a) Section 10.8.1(5)(b): “Members should not discharge their firearms at or from a moving vehicle for the purpose of disabling, or attempting to disable that vehicle.”

(b) Section 10.7(6)(a): Any member making the decision to stop a threat from a person within a motor vehicle using lethal force must adhere to the National Guidelines for Use of Lethal Force.

(c) Section 10.7(6)(b): Safety is the priority in all situations and a high level of awareness and caution must be exercised. The associated risk must be considered against the need to immediately stop the threat and weighed against the risks to the public, the occupants of the vehicle and members.

Firearms training and validation of attending officers

231. Section 10.8 of the TPM provides that officers are not to use a firearm on duty unless validated for the particular firearm within the preceding 12 months of such use.

232. Section 10.8.1(3) provides that operational officers are to undergo a course of instruction and training in the use of firearms at least once per each year. Such instruction and training is to be in accordance with the Firearms Training Manual.

233. Constable Warrington outlined that for officers to comply with current training requirements, they must complete one practice and one validation within a 12-month period. Validation is essentially an accuracy test, whereas practice does not involve formal assessment and is designed to address current issues that have been identified.

234. Constable Chowdhury did not draw or discharge his firearm during the incident but nevertheless was validated to use his firearm.

235. Constable Mitchell was validated for a Glock pistol on 11 September 2019. His validation was current to 11 September 2020 which covers the date of the incident.

236. Significantly, Sergeant Conyers was not validated at the time of the incident. Records indicate his validation expired on 29 November 2019. On 4 March 2020, 16 days after Mr Mason’s death, Sergeant Conyers successfully completed a post-incident validation shoot.

237. In his interview, Sergeant Conyers indicated that he was surprised that his validation had expired, believing that he had undergone validation within the requisite time. He proffered reasons why his validation may have lapsed: “…I was then in the CIB and got transferred to Uniform so firstly the validation reminders and responsibilities etc other than my own changed in that period of time with the CIB office that I was in so yeah I was surprised very surprised… yeah it was certainly not my intention to um like that’s never happened to me and obviously it’s an administrative issue there’s been times however though where I’ve had anomalies in the past with it, it’s not a failsafe system in my view the way it’s done so without wanting to criticise or blame anyone else I think um yeah I’m quite sure I shot in the period that period of time yeah.”

238. During his evidence at the inquest, Sergeant Conyers outlined his understanding of the current validation system. In summary, he stated that validation moved to being an individual officer’s responsibility over the last ten years, and it is for the individual officer to book a training space using the relevant portal. It is also the responsibility of individual officers to submit the paper-based training records in order for the validation to be recorded. The validation appears under the heading Skills in the ESS system. That system also records payslips and leave, and is presumably accessed regularly by officers.

239. Sergeant Conyers stated that in his role as Sergeant he has experienced; (a) inaccurate recording of an officer’s validation status resulting from the training paperwork not being forwarded; and (b) difficulties coordinating dates for validation given there is a single training day for every five-week roster.

240. He further stated that those involved in the training are not usually full-time in this area.

This means the trainer may need to be released from other roles to conduct the training. He thought that the current system could be improved if there was an

increased operational skills component within Tasmania Police and that those involved in the firearms validation training were full-time in that role.

241. Constable Warrington gave evidence that for the period Sergeant Conyers was out of validation (from 19 November 2019 to 17 February 2020) he would not have expected his skills to have degraded in the areas of making a decision to use his firearm; or his physical abilities to operate a firearm correctly. This may well be the case but it is quite reasonable to think that recent validation may well have improved his shooting. It should not be overlooked that training is critical and Sergeant Conyers was not permitted to use a firearm. This meant that he should not have been operational at the time. I am satisfied that Sergeant Conyers was not aware that he was not validated for use of his firearm.

242. Counsel for the Commissioner submitted against a recommendation in favour of electronic reminders to individual officers regarding validation status for the reasons below;

• All members, their supervisors and managers are currently able to access Employee Self Service (ESS) to determine validation status.

• The ability to initiate automated alerts to members and managers does not currently exist within the ESS system and would require significant and costly software development. The development of an alternate recording method for electronic notification would require significant investment in a new information technology platform.

• A further perceived challenge relates to notifying supervisors who change on a regular basis in accordance with the rostering methodology.

• Since February 2020, practices have been enhanced where validation / practice opportunities are now planned in a way that captures all members at the required time. An example is that all Southern District validations occur in the August / September / October months and practices in the 6 months previous. This method assists members and supervisors to identify validation timeframes.

• Tasmania Police is currently in the process of introducing monthly reportable ‘people indicators’, one of which relates to operational validations. This process will further enhance the visibility of individual validations to respective managers.

243. Counsel for the Commissioner outlined that, since the date of Mr Mason’s death, considerable change has occurred in the Operational Skills area as follows;

• In relation to full time staffing, there has been an increase in staff to the Academy Operational Skills Unit from 1 Sergeant and 4 Constables (as at 1 March 2020) to 2 Sergeants and 4 Constables (as at 21 June 2023). An additional Inspector’s position has been created at Education and Training focusing on operational safety with the direct responsibility of overseeing all Recruit and District based operational safety training.

• There is a dedicated training officer in each geographical police district who coordinates and assists in operational skills validations. Consultation is occurring to provide an additional training officer in the Southern District. In field, Operational Skills Instructors are also being utilised to conduct additional ranges to allow greater opportunity for members to validate.

• Tasmania Police now has a dedicated Operational Skills Instructor’s Specialist Group (OSISG) which consists of 42 members. The OSISG have a training regime of 12 days per annum to ensure instructors remain contemporary in all facets of operational safety. These training days also enable flexibility to deliver training to officers in-field. These instructors are further being utilised to conduct additional ranges to allow greater opportunity for members to validate.

• The OSISG are responsible for ensuring: i. That consistent and contemporary operational training is delivered to all members across the state, ii. That emerging risks and trends inform training and policy, and iii. The currency of existing operational safety equipment and where identified, the need to acquire new equipment.

244. These developments are positive and reflect the critical importance of high quality training for officers in operational skills.

Medical assistance rendered to Mr Mason by attending police

245. The body-worn camera footage of Sergeant Conyers, Constable Mitchell and Constable Chowdhury show that, immediately after Sergeant Conyers fired the last of his shots, he advised RDS that shots had been fired and that an urgent ambulance was required.

246. The footage shows that very quickly after Mr Mason was shot: a. Sergeant Conyers, with the assistance of Constable Mitchell, applied a pressure bandage to Mr Mason’s head wound.

b. Mr Mason was then removed from the car by Constable Mitchell and dragged to the rear of the vehicle where he was placed in the supine position; and c. All three officers administered CPR to Mr Mason until the ambulance arrived. They were assisted by other police officers with a defibrillator.

247. I am satisfied that all officers involved in the medical assistance of Mr Mason, including Sergeant Conyers, Constable Chowdhury and Constable Mitchell, acted appropriately and in accordance with their training.

248. The first ambulance arrived at the property at 8.30pm whilst CPR was in progress. It is noted that Mr Mason was not breathing, had no palpable pulse and was unresponsive.

Attempts to ventilate Mr Mason were unsuccessful due to blood in his airways.

249. In light of Dr Ritchey’s evidence, I find that the gunshot wound suffered by Mr Mason led rapidly to his death and that he would not have survived the gunshot wound under any circumstances.

Findings required by s28(1) of the Coroners Act 1995

250. I find that:

(d) The identity of Mr Mason is Geoffrey Russell Mason, born 26 September 1981;

(e) Mr Mason died in the circumstances set out in this finding;

(f) Mr Mason died as a result of a gunshot wound to the neck; and

(g) Mr Mason died on 17 February 2020 at 233 Tea Tree Road, Brighton in Tasmania.

Conclusion

251. The circumstances of Mr Mason’s death have been examined in detail in this investigation.

252. I have concluded that the lethal force used by Constable Mitchell against Mr Mason was justified and proportionate to the threat posed by him. I have also concluded that Sergeant Conyers was fully justified in drawing and discharging his firearm.

253. The strategies, actions and decision-making of the three officers involved in this incident were sound and responsive to the rapidly escalating circumstances. Mr Mason had ample opportunity to submit to the process of lawful arrest but instead, was responsible for his own demise.

254. I have made comments on various further matters within the scope of the inquest and connected to Mr Mason’s death. Since this incident, Tasmania Police has made commendable changes in the areas outlined in this finding.

255. I do not consider that it is appropriate to make any recommendations in this matter.

Acknowledgements

256. I acknowledge, again, the work of Sergeant Steve Herbert (now retired) in leading the coronial investigation into Mr Mason’s death.

257. I also acknowledge the high quality of the evidence provided by experts in the areas of ballistics, crash investigation, forensic pathology and toxicology. In the circumstances of deaths such as that of Mr Mason, it is critical that the coroner has such evidence available.

258. I extend my appreciation to all counsel for their assistance at inquest and helpful closing submissions. I am particularly grateful for the work of counsel assisting, Mr Ransom.

Dated: 30 April 2024 at Hobart in the State of Tasmania Olivia McTaggart Coroner

LIST OF EXHIBITS Record of investigation into the death of GEOFFREY RUSSELL

MASON No. TYPE OF EXHIBIT NAME OF WITNESS CA INVESTIGATION REPORT Detective Sergeant STEVE HERBERT C1 REPORT OF DEATH Detective Sergeant SALLY COTTRELL C2 LIFE EXTINCT AFFIDAVIT Dr ZACHARY ROBINSON C3 ID AFFIDAVIT (POLICE) Sergeant ANTHONY PETERS

C4 ID AFFIDAVIT - MORTUARY TONY CORDWELL AMBULANCE C5 POST MORTEM (PM) / INTERIM PM Dr DONALD RITCHEY C6 NOTES/DIAGRAMS OF PM Sergeant KELLY TAYLOR C7a TOXICOLOGY REPORT NEIL MCLACHLAN-TROUP C7b STAGES OF INTOXICATION FORENSIC SCIENCE SERVICES

TASMANIA C8 STATUTORY DECLARATION WAYNE MAGUIRE (17.02.2020) C9 AUDIO INTERVIEW (Disc) & WAYNE MAGUIRE

TRANSCRIPT (18.02.2020) C10 STATUTORY DECLARATION KAREN MAGUIRE (17.02.2020) C11 AUDIO INTERVIEW (Disc) & KAREN MAGUIRE

TRANSCRIPT (18.02.2020) C12 STATUTORY DECLARATION JENNIFER BISHTON (17.02.2020)

C13 AUDIO INTERVIEW (Disc) & JENNIFER BISHTON

TRANSCRIPT (21.02.2020) C14 VIDEOx3 & AUDIO INTERVIEW XY

(USB) & TRANSCRIPT (17.02.2020) C15 AUDIO INTERVIEW (Disc) & GEOFFREY HARRISON

TRANSCRIPT (18.02.2020) C16 AUDIO INTERVIEW (Disc) & CHARLES ALDERIDGE

TRANSCRIPT (18.02.2020) C17 AUDIO INTERVIEW (Disc) & SHARON GARD

TRANSCRIPT (26.02.2020) C18 AUDIO INTERVIEW (Disc) & JOSEPH JONES

TRANSCRIPT (27.02.2020) C19 STATUTORY DECLARATION Sergeant SCOTT KREGOR (Forensic Services) C20 STATUTORY DECLARATION Constable IAN BELLETTE (Forensic Services) C21 STATUTORY DECLARATION Constable BEN FARQUETT (Forensic Services) C22 STATUTORY DECLARATION Constable REBECCA TURNER (Forensic Services) C23 VIDEO INTERVIEW (Disc) & Constable TIM MITCHELL

TRANSCRIPT (18.02.2020) C24 AUDIO INTERVIEW (USB for C24 & Constable TIM MITCHELL

C23) & TRANSCRIPT (26.06.2020) C25 VIDEO INTERVIEW & Sergeant BRAD CONYERS

TRANSCRIPTION (18.02.20) C26 AUDIO INTERVIEW (Disc), Sergeant BRAD CONYERS

TRANSCRIPT & PHOTOGRAPHS x5 (24.03.20)

C27 AUDIO INTERVIEW (Disc), Constable ABU CHOWDHURY

TRANSCRIPT & HAND DRAWN MAP (18.02.20) C28 RESULTS OF DRUG/ALCOHOL JOHN CELESTI - RELEVANT DRUG TESTING - SERGEANT B TESTING SOLUTIONS CONYERS, CONSTABLES T MITCHELL & CST A CHOWDHURY C29 AFFIDAVIT Detective Sergeant STEVE HERBERT (Investigating Officer) C30 DPP REPORT (BY PROFESSIONAL Detective Inspector MARK WRIGHT

STANDARDS) C31 CODE OF CONDUCT REPORT Detective Sergeant STEVE HERBERT

PROFESSIONAL STANDARDS C32 SUBJECT REPORT Sergeant JASON KLUG C33 SUBJECT REPORT Constable ADRIAN WOODHEAD C34 SUBJECT REPORT Constable MICHAEL KORENSTRA C35 SUBJECT REPORT & BWC Constable HAILEY SINCLAIR FOOTAGE FROM SCENE (Disc) C36 AFFIDAVIT Constable GERARD DUTTON (Ballastics) C37 AFFIDAVIT AND DIAGRAMS X7 Constable KELLY CORDWELL (Crash Investigation Services) C38 AFFIDAVIT PAUL WELLS (Transport Inspector) C39 NOTES OF CONVERSATION Inspector PHILLIPA BURK C40 ESCAD RECORDINGS (Disc X2), TASMANIA POLICE

TRANSCRIPT OF CALLS & INCIDENT (No. 000299-17022020) C41 BWC OF ALL 3 OFFICERS (Disc X2, TASMANIA POLICE & 3D MODELLING (USB with

‘lightened’ BWC footage of all 3 Officers) C42 a. RHH RECORDS – THS Records & TASMANIAN HEALTH SERVICE Medical Imaging (USB, Medical Imaging Disc ) b. MENTAL HEALTH SERVICES RECORDS Vol 1 & 2 (USB/Hardcopy) c. ALCOHOL & DRUGS SERVICES RECORDS (USB/Hardcopy) d. CORRECTIONAL HEALTH RECORDS (USB/Hardcopy) C43 GP RECORDS (part 1 & 2) SORELL DOCTORS SURGERY C44 AFFIDAVITS & DOWNLOAD OF Senior Constable DEAN SHAW & PHONE AND TABLET Senior Segeant ADAM ARCHER C45 Body Worn Camera FOOTAGE TASMANIA POLICE

REVIEW C46 AMR RETRIEVAL RECORD & VACIS AMBULANCE TASMANIA REPORT C47 PHOTOGRAPHS OF SCENE – 23 (on TASMANIA POLICE file and paper based), & PHOTOGRAPHS - 1013 (Disc X2)

C48 TASPOL PRIORS/HISTORY & ON TASMANIA POLICE LINE CHARGING RECORDS C49 POLICE (INTERSTATE) REPORTS TASMANIA POLICE C50 TAS, QLD AND VIC RECORDS NATIONAL POLICE REFERENCE SYSTEM C51 OFFENCE REPORT No.s 173528, TASMANIA POLICE 183787, 205275, 628887& 634644 & FVMS REPORT No. 110319

C52 AUTOMATIC VEHICLE LOCATION TASMANIA POLICE (AVL) Report

C53 SERIOUS SITE DECLARATION & Deputy Inspector TROY MORRISBY

REVOCATION C54a INTERIM LABORATORY REPORT – MICHAEL MANTHEY - FORENSIC

BULLET FRAGMENTS SCIENCE SERVICES TASMANIA C54b FINAL LABORATORY REPORT _ MICHAEL MANTHEY - FORENSIC

BULLET FRAGMENTS SCIENCE SERVICES TASMANIA C55 USE OF FORCE REPORT TASMANIA POLICE C56 DEATH IN CUSTODY AUSTRALIAN INSTITUTE OF NOTIFICATION CRIMINOLOGY C57 FIRE INVESTIGATION REPORT MARK MCCARTHY - SRFIO C58 OPERATIONAL SKILLS Sergeant B CONYERS, Constables T

VALIDATION AND MITCHELL & A CHOWDHURY COMPETENCY RECORDS C59 BRIDGEWATER STATION TASMANIA POLICE EQUIPMENT REGISTER C60a FSST REPORT – BIOLOGY REPORT ANA FLONTA - FORENSIC SCIENCE

SERVICES TASMANIA C60b FSST REPORT – SCENE REPORT ANA FLONTA - FORENSIC SCIENCE

SERVICES TASMANIA C60c EMAIL COMPARISON SAMPLE

C61 TASMANIA POLICE POLICY AND TASMANIA POLICE (PROFESSIONAL TRAINING INCLUDES: STANDARDS)

• OPERATIONAL RESPONSE POLICY

• BODY WORN CAMERA POLICY

• BODY WORN CAMERA GUIDELINES C62 OPERATIONAL SAFETY TACTICS TASMANIA POLICE C63 FIREARMS MANUAL V8.1 TASMANIA POLICE

C64 TASMANIA POLICE MANUAL TASMANIA POLICE EXTRACTS C65 PROPERTY INFORMATION REPORT THE LIST – PROPERTY ID 7747617 C66 AFFIDAVIT Sergeant LORETTA ASHWOOD

C67 PHOTOGRAPH FOLDER 1 2808 FIRE EXAM 6674 – 6737 C68 PHOTOGRAPH FOLDER 2 2701 BALLISTICS MV EXAM 0196 – 0412 C69a PHOTOGRAPH FOLDER 3 C69a – 2106 Ballistics 6738 – 9752 -d C69b – 2808 AIS Photos 6803 – 6815 C69c – 2106 inside Magna 9736 – 9743 C69d – 2106 AIS Photos 9644 - 9717 C70a AFFIDAVIT 30.3.23, AFFIDAVIT First Class Constable ROD -c 3.4.23, FIREARM DIAGNOSTIC WARRINGTON

TOOL C71a- REASONS FOR SENTENCING, TASMANIA POLICE c PROSECUTION FACTS &

RECORD OF PRIOR CONVITIONS C72 ESCAD CONCERN FOR TASMANIA POLICE WELFARE233 TEA TREE ROAD BRIGHTON C73 OFFENCE REPORT OR191759 TASMANIA POLICE C74 TPM AMENDMENT - DISCHARGING TASMANIA POLICE OF FIREARMS AT A VEHICLE OR THREAT C75a AFFIDAVIT – 29.6.23 & AFFIDAVIT – Assistant Commissioner TASMANIA

& 24.7.23 POLICE, GLENN KEATING b