Deceased
Nicholas Aaron Scott
Demographics
26y, male
Date of death
2023-01-03
Finding date
2025-08-29
Cause of death
shotgun wound of the chest
AI-generated summary
Nicholas Aaron Scott, a 26-year-old prisoner with a history of self-harm, escaped from Royal Hobart Hospital on 2 January 2023 while under correctional officer supervision. He had been admitted for ingestion of foreign objects. Two correctional officers failed to follow security protocols: they removed his handcuffs despite explicit instructions he be restrained at all times, permitted an unauthorised phone call, did not maintain proper positioning at the toilet door, and failed to react promptly when he fled. The escape was entirely preventable through adherence to established procedures. Scott subsequently became involved in a violent altercation and was fatally shot by David Coles. The coroner found both officers failed their duty to guard Scott and exercise basic security vigilance, though the escape itself did not directly cause his death.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
FINDINGS of Coroner Simon Cooper following the holding of an inquest under the Coroners Act 1995 into the death of Nicholas Aaron Scott
Contents
Record of Investigation into Death (With Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Simon Cooper, Coroner, having investigated the death of Nicholas Aaron Scott with an inquest held at Hobart in Tasmania make the following findings: Hearing Dates 26 and 27 May 2025.
Representation1 E Burrows-Cheng - Counsel Assisting the Coroner L Taylor - Tasmanian Prison Service (Secretary of the Department of Justice) R Ralston - M Oppitz Introduction
It is not any part of my role to comment on the criminal proceedings relating to Mr Coles.
Role of the Coroner
that death if it appears to have been “unexpected, unnatural or violent or to have resulted directly or indirectly from … injury”.2 The circumstances of Mr Scott’s death meet this definition.
A preliminary question arose as to whether or not at the time of his death Mr Scott was in custody or was in the process of escaping from custody. The significance of this point was that if either of those factual scenarios applied, then I would have had an obligation to first, hold an inquest and second, after holding the inquest, report on Mr Scott’s care, supervision and treatment.3 I determined that neither scenario was applicable since Mr Scott had made good his escape and there was a sufficient temporal and geographical disconnection between his being in custody and escaping and his death.
When conducting an inquest, a coroner performs a role different to other judicial officers. The coroner’s role is inquisitorial. An inquest might be best described as a quest for the truth, rather than a contest between parties to either prove or disprove a case. In an inquest, a coroner is required to thoroughly investigate the death and answer the questions (if possible) that section 28(1) of the Coroners Act 1995 (the “Act”) asks. Those questions include who the deceased was, how they died, the cause of the person’s death, and where and when the person died. It is settled law that this process requires a coroner to make various findings, but without apportioning legal or moral blame for the death.
In any event, a coroner is required to make findings of fact about the death from which others may draw conclusions. A coroner may, if she or he thinks fit, make comments about the death or, in appropriate circumstances, recommendations to prevent similar deaths in the future.4
It is important to recognise that a coroner does not punish or award compensation to anyone.5 Punishment and/or compensation are for other proceedings, in other courts, if appropriate. Nor does a coroner charge people with crimes or offences arising out of a death that is the subject of investigation.
As was noted above, one matter that the Act requires, is a finding (if possible) as to how the death occurred.6 ‘How’ has been determined to mean ‘by what means and in 2 Section 3 of the Act.
3 Section 28(5) of the Act.
4 Section 28(2) of the Act.
5 Section 45(3) of the Act.
6 Section 28(1)(b) of the Act.
what circumstances’,7 a phrase which involves the application of the ordinary concepts of legal causation.8 Any coronial inquest necessarily involves a consideration of the particular circumstances surrounding the death so as to discharge the obligation imposed by section 28(1)(b) upon the coroner.
The standard of proof at an inquest is the civil standard. This means that where findings of fact are made, a coroner needs to be satisfied on the balance of probabilities as to the existence of those facts. However, if an inquest reaches a stage where findings being made may reflect adversely upon an individual, it is well-settled that the standard applicable is that expressed in Briginshaw v Briginshaw, that is, that the task of deciding whether a serious allegation against anyone is proved should be approached with a good deal of caution.9
A coroner is not bound by the rules of evidence in holding an inquest and may be informed and conduct an inquest in any manner the coroner reasonably thinks fit. To be properly received at an inquest, the evidence must be capable in some way of assisting the coroner to determine the matters under section 28(1) or, in appropriate circumstances, to assist in making a comment or recommendation. It is well settled that a coroner has significant latitude in receiving evidence. The question of weight to be given to any evidence tendered at an inquest is a question for the coroner after receiving submissions from interested parties.
The final matter that should be highlighted is the fact that the coronial process, including an inquest, is subject to the requirement to afford procedural fairness.10 A coroner must ensure that any person (any person can include a legal entity) who might be the subject of an adverse finding or comment is made aware of that possibility and given the opportunity to fully put their side of the story forward for consideration. To that end all persons and entities considered to have sufficient interest in the outcome of the inquest, and who may have been at risk of adverse comment, were identified well in advance of the inquest, provided with notice and invited to participate in that inquest.
Their participation was facilitated by the complete disclosure of all material obtained as a result of the investigation under the Act.
7 Atkinson v Morrow [2005] QCA 353.
8 See March v MH Stramare Pty Ltd and Another [1990 – 1991] 171 CLR 506.
10 See Annetts v McCann (1990) 170 CLR 596, Attorney General v Copper Mines of Tasmania Pty Ltd [2019] TASFC.
Evidence at the inquest
In addition to the verbal evidence given at the inquest a significant amount of written material was tendered. That material is annexed to this finding and marked with the letter A.
Well in advance of the inquest Mr Scott’s senior next of kin (his mother) was notified of the fact that an inquest would be held in relation to her son’s death. She took no part in the proceedings.
Background
On 29 November 2021, Mr Scott was convicted of aggravated carjacking and sentenced to three years and six months imprisonment. On 30 May 2022, he was released on parole subject to various conditions which, within a month, he breached and was consequently arrested. His parole was revoked on and from 1 July 2022.
On 3 November 2022, Mr Scott was moved from the Hobart Reception Prison to the Risdon Prison Complex where he was housed in the maximum security Huon Unit. On 1 December 2022, Mr Scott was admitted to the Royal Hobart Hospital after swallowing two razor blades wrapped in plastic. He remained at the Royal Hobart Hospital until his discharge on 20 December 2022 whereupon he was returned to maximum security in the Risdon Prison Complex.
A week later, on 27 December 2022, Mr Scott was again admitted to the Royal Hobart Hospital due to self-inflicted cuts to his upper chest. After his admission, he told staff that he had swallowed another razor blade. An x-ray confirmed that he had not
swallowed a razor blade but had swallowed a small piece of metal from a facemask which was not considered to cause him any risk. He was duly returned to the Risdon Prison Complex after receiving wound care.
While at the hospital, he swallowed a key to a paper towel dispenser. Another x-ray was performed and the presence of the key in his intestines identified. A decision was made to admit Mr Scott until he passed the key.11 Applicable policies
On 2 January 2022, Mr Scott was in the custody of the Tasmanian Prison Service at the Royal Hobart Hospital. He was a patient in room 3 of level 6A. The circumstances of his incarceration were governed by Director’s Standing Order (DSO) 1.20.12 That DSO, entitled “External Escorts, Medical Appointments and Hospital Admissions”, was the relevant policy document in force dealing with Mr Scott circumstances at the time he escaped from custody.
Relevantly the DSO provides: “Where two or more officers are assigned to supervise a prisoner, the prisoner is not to be left unsupervised at any time, except where sensitive treatment or examination is required, the prisoner is undergoing surgery or is incapacitated”.13
The DSO also provides that in the case of a prisoner having access to a room (such as for example a hospital room ensuite) without direct correctional supervision, then the supervising officer or officers must be stationed directly outside the door of that room.
It also requires the completion of a document known as an “Escort Risk Assessment” (Form 5BV) prior to a prisoner being transported. The evidence at the inquest was that the relevant assessment document was in fact completed but not included in the escort bag that accompanied Mr Scott to the hospital. The DSO also deals with the procedures that are to be followed in the event of an emergency including an escape. In summary, in the event of an escape, the DSO requires prison staff to be notified as soon as possible and the escorting officers involved to immediately notify Tasmania Police by calling 000.
11 All this information is extracted from his prison and medical records.
12 Exhibit C49.
13 Supra, Item 12 of appendix D.
The evidence was that a prisoner escort kit in a clear shoulder bag was present in Mr Scott’s room. It included a prisoner profile, mobile phone, handcuffs, a duty log and a suicide and self-harm log.
A risk assessment had been carried out in relation to Mr Scott. It identified a twoperson escort team was required, that he was to be handcuffed at all times and was not permitted to make any phone calls.14 That risk assessment was not included in the escort bag. The evidence was that at the relevant time there was no requirement for the document to be included in the escort bag; the inclusion of the document is now mandatory.
Finally, the DSO required the escort mobile phone to be in the physical possession of a custodial officer at all times.
Circumstances of Death
At the time (approximately 6.10 pm on 2 January 2023) First Class Correctional Officer (FCCO) Martin Oppitz arrived at the Royal Hobart Hospital to commence a night shift, by then Mr Scott had spent a total of 25 days and part days as an inpatient in the Royal Hobart Hospital over the previous month or so. All of those days had been without incident.
Shortly after FCCO Oppitz arrived, Correctional Officer (CO) Craig Cox joined him.
The shift that the men were due to work was a 12 hour shift from 7.00 pm to 7.00 am.
It was the duty of both officers to guard Mr Scott both to protect the community and ensure his safety. I have concluded on the basis of the evidence at the inquest that both failed to perform their duty.
Before they arrived, Mr Scott had been fasting with a view to undergoing surgery that evening. However the surgery was cancelled and Mr Scott was permitted to eat, something he was doing when CO Cox arrived.15
When FCCO Oppitz arrived, Mr Scott was handcuffed by his left arm to the hospital bed. I am satisfied that upon arrival FCCO Oppitz said words to the effect “why have they got you handcuffed”.16 There followed a handover of sorts although I am satisfied that the handover between day and night shift was essentially ineffectual, although I do not think that the poor handover was to blame for what occurred; rather to my mind 14 Exhibit C 48(h)(iii).
15 Exhibit C 35.
16 Exhibit C48, page 8.
it is indicative of a generally lax approach to the task at hand, an approach not confined to the officers on duty when Mr Scott escaped.17
CO Cox was not present for the handover although he was familiar with Mr Scott having dealt with him before in prison. CO Cox knew that Mr Scott was housed in the maximum security unit and his understanding was that he was in hospital due to a suicide/self-harm incident. CO Cox was handed the handcuff key by FCCO Oppitz and took (or at least had) responsibility for removing and reapplying the handcuffs as required.
I am satisfied that FCCO Oppitz was the senior officer, despite his assertions to the contrary. I have no doubt CO Cox treated him as the senior both due to his rank and his experience in the position.
The evidence was that both officers were at the hospital because both had accepted what was in effect an “overtime” shift at the hospital. Neither had worked with each other before and neither knew the other. I am satisfied that when FCCO Oppitz accepted the shift he was unfit for work by reason of having been stung on the left ankle by a bee. I note his evidence that he considered he was fit for the shift, but I reject that evidence. It sits uncomfortably with the fact that he removed his footwear to provide relief from the pain of the bee sting. He should not have been at work; however, he was.
Mr Scott’s security rating (maximum) meant that he was supposed to be handcuffed at all times. Both officers were supposed to be vigilant and positioned in a way so as to prevent Mr Scott from escaping or harming himself.
I am satisfied that FCCO Oppitz, in addition to having removed his shoes sometime around 9.00 pm, was wearing headphones listening to music as well as having reclined the position of the chair in which he was sitting. CO Cox chatted to Mr Scott as they watched cricket. Mr Scott was handcuffed by his left hand to the hospital bed. He used the toilet frequently, something both officers considered to have been due to the medication he was taking. The atmosphere appears to have been relatively relaxed, of which I make no criticism.
However, there were matters which do give rise to concern. First, both officers knew, or should have known, that Mr Scott was not permitted to make a telephone call.
17 See generally Exhibit C48 and in particular page 6.
Nonetheless, FCCO Oppitz permitted him to make a call at about 9.00 pm of approximately 20 minutes duration to his former girlfriend (and mother of his then three year old son) Ms Billi Jo Howlett. During that call, Mr Scott was evidently loud and strident and used an expression to the effect that someone was a “fucking dog and is going to get murdered” - although neither officer seemed to consider that the call gave rise to any concern.
Second, the escort log (the completion of which was a mandatory requirement) was not even commenced by either of the correctional officers until after Mr Scott had escaped.
Third, and most importantly in the context of his actual escape, both officers knew that there were no circumstances where Mr Scott was entitled to have his handcuffs removed. Despite this his handcuffs were removed and Mr Scott was allowed to sit at the table and write a letter, fully clothed.
The critical series of events commenced at about 10.35 pm when CO Cox again removed the handcuffs after Mr Scott asked to use the toilet. He also was again provided with his clothes. Mr Scott entered the room’s en-suite. I am satisfied neither officer positioned themselves so as to protect the door or monitor properly Mr Scott in the toilet. As a result he was able to run out of the room (at 10.47 pm) towards a nearby stairwell and make his escape.
CCTV footage shows a clear six second gap before FCCO Oppitz in socks gave chase to Mr Scott. In the context of the escape, six seconds is a very long time indeed.
The same footage shows the officers discontinuing their pursuit of Mr Scott at the stairwell. Neither had the escort mobile phone in their possession.
In summary, if the officers had been doing their job properly, that is maintained the handcuffs on Mr Scott, positioned themselves so as to cover both the toilet and room doors, been appropriately vigilant, reacted quickly and actually given chase then it is reasonable to conclude that Mr Scott would not have escaped from the Royal Hobart Hospital.
Various excuses were offered by the officers and in particular FCCO Oppitz as to how and why it was that Mr Scott was able to escape. The common theme of those excuses was officers were somehow not to blame. I reject that evidence. As Counsel Assisting accurately submitted in my view, FCCO Oppitz was argumentative, dismissive and
generally evasive when he gave his evidence. He was a poor witness who refused to accept any responsibility on his part for Mr Scott’s escape. CO Cox was also unimpressive as a witness, for example, telling investigators that he had no memory of Mr Scott writing a letter, fully dressed and uncuffed, nor any memory of FCCO Oppitz leaving the room at various times.
They also failed to exercise plain common sense.
I have already said that I accept that no risk assessment form was in fact present in the escort kit on the night in question and that this was a failure of process. That having been said, it is to my mind almost impossible to see what practical difference its absence would have made.
I should say that I reject unreservedly any suggestion that a lack of training (or in the case of FCCO Oppitz, experience) was in any way a factor in the escape. CO Cox had very recently completed his recruit course and the evidence makes it quite clear that he had received appropriate training in relation to the circumstances he found himself in the Royal Hobart Hospital on 2 January 2022. And put simply, FCCO Oppitz should have known better.
In any event, Mr Scott made his way to Salamanca where he borrowed a mobile phone from a member of the public, called a taxi and made his way to his former girlfriend’s house at George Street, Granton. After using illicit drugs there, he was taken by Hayden Leigh Jetson on the back of a motor bike to the home of Brock Callum Davey at 123 Black Snake Road, Granton, a short distance away from George Street.
Within minutes of arriving at the address in Black Snake Road, Mr Scott was involved in a chaotic and violent scuffle with Mr Davey and Coles, the latter having arrived with a loaded double barrel sawn off shot gun. During the scuffle, Mr Scott hit Coles in the head with a bottle and threatened to stab someone. Mr Davey suffered wounds to his face. The scuffle spilled outside the house and at 1.35 am on Monday, 3 January 2023 Coles shot Mr Scott in the chest. He died almost instantly and Coles fled the scene.
Forensic and ballistic evidence
In both chambers of the weapon were fired 12-gauge cartridge cases. The weapon and fired cartridge cases were seized for subsequent ballistic investigation.18
Mr Scott’s body was identified at the scene by Sergeant Rance Swinton,19 before being taken by mortuary ambulance to the Royal Hobart Hospital. At the Royal Hobart Hospital highly experienced forensic pathologist Dr Donald Ritchey performed an autopsy. Dr Ritchey prepared a report after that autopsy which was tendered at the inquest.20 In that report Dr Ritchey expressed the opinion, which I accept, that the cause of Mr Scott’s death was a shot gun wound of the chest.
Toxicological analysis of samples taken at autopsy revealed that both methylamphetamine and cannabis were present in Mr Scott’s body at the time of his death.
At the autopsy, Dr Ritchey recovered the plastic wad/shot cup from the wound track and multiple spherical shot pellets. Those items were handed directly to Sergeant Dutton of the Ballistics Section who was also present at the autopsy. Sergeant Dutton carried out extensive investigations in relation to the weapon, cartridges and scene of Mr Scott’s death. He provided his usual detailed and instructive report which was tendered at the inquest.21 Sergeant Dutton expressed the opinion, which I accept, that both cartridges had been fired by the shot gun recovered from the neighbouring yard and that it was discharged at a distance of somewhere between 3.25 m and 4 m from Mr Scott. There is no evidence that the weapon was ever lawfully registered.
The barrel of the weapon itself had been shortened, and the butt had also been removed. Despite these modifications, ballistic testing showed that it was not prone to accidental discharge and was fitted with an efficient safety catch. I am satisfied that Mr Scott’s death was not the result of an accidental discharge of the weapon.
18 It was subsequently determined that although Coles only fired one shot at Mr Scott, he discharged the weapon shortly after as he was fleeing the scene.
19 Exhibit C2.
20 Exhibit C4.
21 Exhibit C 27.
Formal Findings
Conclusion
In the circumstances there is no need for me to make any further comment or recommendations.
In conclusion, I wish to express my thanks to all counsel involved in the inquest.
Dated: 29 August 2025 at Hobart in the State of Tasmania.
Simon Cooper Coroner
Annexure A
LIST OF EXHIBITS Record of investigation into the death of Nicholas Aaron Scott No. TYPE OF EXHIBIT NAME OF WITNESS
C1 POLICE REPORT OF DEATH DET SEN SGT D. LATHAM C2 AFFIDAVIT OF IDENTIFICATION - A/SGT RANCE SWINTON POLICE C3 AFFIDAVIT OF IDENTIFICATION ANTHONY C. CORDWELL C4 POSTMORTEM AFFIDAVIT DR DONALD M. RITCHEY C4a IPM DR DONALD M. RITCHEY
C5 TOXICOLOGY REPORT NEIL MCLACHLAN-TROUP - FSST C6 MEDICAL RECORDS THS C6a MEDICAL RECORDS – (Scans of ingestion of THS razor blades)
C7 MEDICAL RECORDS CPHS C8 STATUTORY DECLARATION SGT DARREN J. WILLIAMS C8a BWC SGT DARREN J. WILLIAMS C8b AFFIDAVIT SGT DARREN J. WILLIAMS C8c PHOTOGRAPH OF BROCK DAVEY SGT DARREN J. WILLIAMS
FEATHERSTONE C9a BWC CST MONIQUE K.
FEATHERSTONE C10 STATUTORY DECLARATION CST TRACEY L. SMITH-REES C10a BWC CST TRACEY L. SMITH-REES
C11 STATUTORY DECLARATION S/CST ANNIKA COLES C11a BWC S/CST ANNIKA COLES
C12 STATUTORY DECLARATION CST SCOTT STEHN C12a BWC CST SCOTT STEHN
C13 STATUTORY DECLARATION CST RAQUEL M. O’NEILL C13a BWC – arriving at scene CST RAQUEL M. O’NEILL C13b BWC – speaking with Stacey Maxwell CST RAQUEL M. O’NEILL
C14a BWC – 2 videos CST JESSICA K. LEEK
C15 STATUTORY DECLARATION CST CAMERON BLIGHT C15a BWC – 8 videos CST CAMERON BLIGHT
C16 STATUTORY DECLARATION CST MATTHEW REARDON C17 STATUTORY DECLARATION CST CRAIG P. FRY C18 STATUTORY DECLARATION CST ELLEN M. OSBORNE C19 STATUTORY DECLARATION (CURRENTLY 1/C) ANNA M.
SEYMOUR C20 STATUTORY DECLARATION 1/C JACOB HARRIS C21 STATUTORY DECLARATION CST THOMAS D. M. SHERMAN C22 STATUTORY DECLARATION CST STACEY G. FOX C23 STATUTORY DECLARATION STACEY D. MAXWELL C24 STATUTORY DECLARATION KADE T. DAVEY C25 STATUTORY DECLARATION – CRIME CST IAN J. BELETTE SCENE EXAMINER – FORENSIC SERVICES C25a PHOTOS – 419 photos CST IAN J. BELLETTE
C26 STATUTORY DECLARATION – S/C TAMI M. NELSON SOUTHERN DRUG INVESTIGATION SERVICES – FORENSIC SERVICES C26a PHOTOS – 34 photos S/C TAMI M. NELSON
C27 STATUTORY DECLARATION – SGT GERARD DUTTON BALLISTICS – FORENSIC SERVICES C27a PHOTOS – 16 photos SGT GERARD DUTTON
C28 STATUTORY DECLARATION S/C BROOKE M. JOHNSON C29 STATUTORY DECLARATION RENEE M. BOWERMAN C30 STATUTORY DECLARATION MELISSA L. LUTTRELL C31 STATUTORY DECLARATION PAUL I. CANTRELL C32 STATUTORY DECLARATION – ASHLEY SMALL SURVEILLANCE C32a CCTV FOOTAGE – NICHOLS VISITING ASHLEY SMALL
DAVEY C32b CCTV FOOTAGE – BARROW ARRIVING ASHLEY SMALL
AT DAVEY’S C32c CCTV FOOTAGE – SCOTT AND JETSON ASHLEY SMALL
ARRIVE AT DAVEY’S C32d CCTV FOOTAGE – COLES AND BARROW ASHLEY SMALL
C32e CCTV FOOTAGE – COLES LEAVING ASHLEY SMALL
BLACK SNAKE ROAD C32f CCTV FOOTAGE – BARROW AND JETSON ASHLEY SMALL
LEAVING BLACK SNAKE ROAD C33 STATUTORY DECLARATION SHIMARRA A. MCDONALD C34 STATUTORY DECLARATION 1/C CORRECTIONAL OFFICER MARTIN J. OPPITZ C35 STATUTORY DECLARATION CORRECTIONAL OFFICE CRAIG A. COX C36 STATUTORY DECLARATION – RHH – ADAM COAD SURVEILLANCE C36a CCTV FOOTAGE – RHH LIFT FOYER 1 RHH C36b CCTV FOOTAGE – RHH LIFT FOYER 2 RHH C36c CCTV FOOTAGE – RHH ENTRY RHH C36d CCTV FOOTAGE – RHH KGW RAMP RHH C36e CCTV FOOTAGE – RHH KLW RAMP RHH C37a CCTV FOOTAGE – COLLINS HOBART CITY COUNCIL
STREET/RIVULET C37b CCTV FOOTAGE – ARGYLE STREET AND HOBART CITY COUNCIL
COLLINS C37c CCTV FOOTAGE – BUS MALL – COLLINS HOBART CITY COUNCIL
STREET C37d CCTV FOOTAGE – COLLINS STREET HOBART CITY COUNCIL
EAST C37e CCTV FOOTAGE – COLLINS COURT HOBART CITY COUNCIL
NORTH C37f CCTV FOOTAGE – COLLINS COURT HOBART CITY COUNCIL
COFFEE SHOP C38 STATUTORY DECLARATION CORRECTIONAL SUPERVISOR LARA SMITH C39 STATUTORY DECLARATION SUPERINTENDENT NICOLE GORNIK C40 STATUTORY DECLARATION MEDICAL ORDERLY KYLE J. CHALLENGER C41 STATUTORY DECLARATION JAMES O. FIELDING C42 STATUTORY DECLARATION ALI RAZA C43a CCTV FOOTAGE – SALAMANCA – JACK HOBART CITY COUNCIL
C43b CCTV FOOTAGE – SALAMANCA – SALAMANCA MEWS
SALAMANCA MEWS – COURTYARD ROAD C43c CCTV FOOTAGE – SALAMANCA – SALAMANCA MEWS
SALAMANCA MEWS – COURTYARD PARK C44a 000 – S. MAXWELL – FIRST CALL TASPOL C44b 000 – S. MAXWELL – CALL BACK TASPOL C44c 000 – S. MAXWELL – CALL BACK TASPOL
ENHANCED C45a CCTV FOOTAGE – NEIGHBOURING POLICE
PROPERTY C45b CCTV FOOTAGE - NEIGHBOURING POLICE
PROPERTY – DRIVEWAY 1 C45c CCTV FOOTAGE - NEIGHBOURING POLICE
PROPERTY – DRIVEWAY 2 C46 CCTV FOOTAGE - GUN OVER FENCE NEIGHBOUR C47a BWC - Arrest CST STACEY G. FOX C47b BWC - Arrest 1/C JACOB HARRIS C47c BWC - Arrest CST THOMAS D. M. SHERMAN
C48 TPS – INVESTIGATION REPORT TPS C48a ADMISSION FORM (12.04.15) TPS C48a(i) ADMISSION FORM (08-09.05.15) TPS C48a(ii) ADMISSION FORM (2.07.16) TPS C48a(iii) ADMISSION FORM (28.10.17) TPS C48a(iv) ADMISSION FORM (6.07.18) TPS C48a(v) ADMISSION FORM (10.12.18) TPS C48a(vi) ADMISSION FORM (5.8.19) TPS C48a(vii) ADMISSION FORM (10.12.21) TPS C48a(viii) ADMISSION FORM (24.04.22) TPS C48a(ix) ADMISSION FORM (1.7.22) TPS C48b EPISODE SUMMARY (11.04.15) TPS C48b(i) EPISODE SUMMARY (8.05.15) TPS C48b(ii) EPISODE SUMMARY (2.07.16) TPS C48b(iii) EPISODE SUMMARY (28.10.17) TPS C48b(v) EPISODE SUMMARY (6.07.18) TPS C48b(vi) EPISODE SUMMARY (10.12.18) TPS
C48b(vii) EPISODE SUMMARY (5.08.19) TPS C48b(viii) EPISODE SUMMARY (9.10.19) TPS C48b(ix) EPISODE SUMMARY (10.12.21) TPS C48c INTELLIGENCE SUMMARY (07.01.23) TPS C48d THERAPEUTIC SUMMARY (06.01.23) TPS C48d(i) SASH OBSERVATION CHECKLIST TPS (28.12.22) C48e HOSPITAL ADMISSION LOG (29.12.22) TPS C48f CPHS NURSE NOTES (date unknown) TPS C48g RISK TREATMENT PLAN (29.12.22) TPS C48h EXTERNAL ESCORT RISK ASSESSMENT TPS (27.11.22) C48h(i) EXTERNAL ESCORT RISK ASSESSMENT TPS (29.11.22) C48h(ii) EXTERNAL ESCORT RISK ASSESSMENT TPS (15.12.22) C48h(iii) EXTERNAL ESCORT RISK ASSESSMENT TPS (29.12.22) C48i INTERVIEW NOTES – IAN THOMAS TPS (17.01.23) C48j INTERVIEW NOTES – NICOLE GORNIK TPS (13.01.23) C48k INTERVIEW NOTES – TRENT NEWMAN TPS (16.01.23) C48l INTERVIEW NOTES – CHRISTOPHER TPS
REVELL (17.01.23) C48m INTERVIEW NOTES – JULIAN WILLIAMS TPS (12.01.23) C48n INTERVIEW NOTES – LARA SMITH TPS (12.01.23) C48o INTERVIEW NOTES – MARTIN OPPITZ #1 TPS (17.01.23) C48o(i) INTERVIEW NOTES – MARTIN OPPTIZ #2 TPS (20.01.23) C48o(ii) INTERVIEW NOTES – MARTIN OPPITZ #3 TPS (unsigned) 30.01 (year unknown) C48o(iii) EMAIL – MARTIN OPPITZ (02.02.23) TPS C48p INTERVIEW NOTES – Dr ONU (16.02.23) TPS
C48q INTERVIEW NOTES – CLYDE TUITE TPS (16.01.23) C48r INTERVIEW NOTES – LAUREN CLARK TPS (17.01.23) C48s INTERVIEW NOTES – DAVID TPS
CARTWRIGHT (03.02.23) C48t INTERVIEW NOTES –LARA HALL AND TPS
REMMY STEEL (09.01.23) C48u INTERVIEW NOTES – GEORGIA SALTER, TPS
MEGAN COOPER, TRISTAN STREFLAND (11.01.23) C48v INTERVIEW NOTES – CRAIG COX #1 TPS (17.01) (year unknown) C48v(i) INTERVIEW NOTES – CRIAG COX #2 TPS (31.01) (year unknown) C48v(ii) EMAIL – CRAIG COX (06.02.23) TPS C48w PHONE CONVERSATION NOTES – M. TPS
CAUSBY (08.02.23) C48x STATUTORY DECLARATION – CRAIG TPS
COX (03.01.23) C48y STATUTORY DECLARATION – MARTIN TPS
OPPITZ (04.01.23) C48z STATUTORY DECLARATION – NICOLE TPS
GORNIK (03.01.23) C48aa INCIDENT REPORT – LARA HALL TPS (03.01.23) C48ab INCIDENT REPORT – REMMY STEEL TPS (03.01.23) C48ac INCIDENT REPORT – MARTIN OPPITZ TPS (03.01.23) C48ad INCIDENT REPORT – CRAIG COX TPS (03.01.23) C48ae INCIDENT REPORT – NICOLE GORNIK TPS (03.01.23) C48af INCIDENT REPORT – LARA SMITH TPS (03.01.23) C48ag WITNESS STATEMENTS – GEORGIA TPS
C48ah EMAIL CORRESPONDENCE RE NIGHT TPS
SHIFT COVER – NICOLE GORNIK (05.01.23) C48ai EMAIL CORRESPONDENCE RE POSSIBLE TPS
MANIPULATIONS – KELLIE WATSON (05.01.23) C48aj EMAIL CORRESPONDENCE RE ESCORT TPS
STAFF BEHAVIOURS AT RHH – JASON MILLS (09.01.23) C48ak EMAIL CORRESPONDENCE RE ESCORT TPS
DIFFICULTIES – JASON MILLS (11.01.23) C48al EMAIL CORRESPONDENCE RE TPS
ABORIGINALITY QUESTION – AMANDA RIPPER (25.01.23) C48am CRAIG COX CONTROL AND TPS
CONSTRAINT ASSESSMENT C49 DIRECTORS STANDING ORDER – EXTERNAL ESCORTS, MEICAL TPS APPOINTMENTS AND HOSPITAL ADMISSIONS C50 LETTER FROM RHH RE UPDATED MOU TPS WITH TPS – SECURITY ARRANGEMENTS C50a LETTER FROM CORRECTIVE SERVICES TPS to DOH regarding RHH SECURITY
ARRANGEMENTS C51 HOSPITAL ADMISSION LOG – BOOK 1 TPS C51a HOSPITAL ADMISSION LOG – BOOK 1 – TPS
FORM 5BB C52 COMMENTS ON PASSING SENTENCE – SUPREME COURT COLES – 7.3.24 – J. PORTER C53 MEMORANDUM OF SENTENCE – DAVID I. SUPREME COURT COLES C54 NOTICE OF APPEAL – DAVID I. COLES SUPREME COURT C54a EMAIL FROM SUPREME COURT – SUPREME COURT
APPEAL WITHDRAWN C55 TRANSCRIPT – BILLI-JO R. HOWLETT TASPOL C56 TRANSCRIPT – HAYDEN L. JETSON TASPOL C57 TRANSCRIPT – SHAUN G. BARROW TASPOL C58 TRANSCRIPT – DAVID I. COLES TASPOL C59 AFFIDAVIT OF LARA SMITH DATED LARA SMITH (tendered at inquest 26/05/2025 on 26/05/2025)
C60 AFFIDAVIT OF KASEY DREW DATED KASEY DREW (tendered at inquest 26/05/2025 on 26/05/2025)
C61 DIAGRAM OF HOSPITAL ROOM TPS (ANNEXURE 4) C62 DIAGRAM OF HOSPITAL ROOM TPS (ANNEXURE 5) C63 POWERPOINT OF CORRECTIONAL TPS OFFICER TRAINING C64 TPS INTERNAL MEMORANDUM (dated TPS 11/01/2023)
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