Coronial
VICother

Finding into death of Carl Anthony Williams

Deceased

Carl Anthony Williams

Demographics

39y, male

Coroner

State Coroner Judge Ian L Gray

Date of death

2010-04-19

Finding date

2014-04-09

Cause of death

Blunt Head Injury

AI-generated summary

Carl Anthony Williams, aged 39, was murdered in prison by fellow inmate Matthew Johnson via repeated blunt head trauma with an exercise bike component. Williams was incarcerated serving a life sentence and had made statements to police about police corruption, making him a Crown witness. The critical clinical lesson concerns the failure of prison authorities to adequately assess and manage the identified security risk posed by Johnson to Williams, despite documented evidence that Johnson knew about Williams's cooperation with police and had access to Williams's statements. The coroner noted that Justice Lasry questioned how prison authorities permitted Williams to spend significant time in Johnson's company, given Johnson's known opposition to prisoners who cooperated with authorities. While the coroner deferred to extensive external investigations, the case highlights systemic failures in risk assessment and protective custody management in high-security prison settings.

AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.

Error types

systemcommunication

Contributing factors

  • Failure to adequately segregate prisoner known to pose a threat to the deceased
  • Insufficient monitoring of contact between the deceased and Matthew Johnson
  • Inadequate risk assessment regarding Johnson's opposition to prisoners cooperating with police
  • Access granted to Johnson to deceased's police statements
  • Failure to implement protective custody measures despite documented concerns

Coroner's recommendations

  1. Findings affirm recommendations already made by the Victorian Ombudsman (57 recommendations regarding Corrections Victoria management and placement of prisoners)
Full text

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE COR 2010 1468

FINDING INTO DEATH WITHOUT INQUEST

Form 38 Rule 60(2) Section 67 of the Coroners Act 2008

I, Judge Ian Gray, State Coroner having investigated the death of Carl Anthony Williams

without holding an inquest:

find that the identity of the deceased was Carl Anthony Williams

born 13 October 1970

and the death occurred on 19 April 2010

at the Acacia High Security Unit, HM Prison Barwon, 1140 Bacchus Marsh Road, Lara

from: 1 (a) Blunt Head Injury

Pursuant to section 67(2) of the Coroners Act 2008, I make findings with respect to the following

circumstances:

i Carl Anthony Williams was 39 years of age at the time of his death. He was the son of Mr George Williams and Mrs Barbara Williams (who died in 2008). Mr Williams married Roberta Williams in 2001 and they had one daughter, Dhakota Williams.

  1. Mr Williams was murdered on 19 April 2010 in the Acacia High Security Unit, HM Prison Barwon where he was serving a sentence of life imprisonment with a non parole period of 38 years for the murders of Jason and Lewis Moran, Mark Malia and Michael Marshall as well as conspiracy to murder Mario Condello. He had previously been

sentenced for trafficking a drug of dependency.

BA A post mortem examination was undertaken by Dr Melissa Baker, Forensic Pathologist

with the Victorian Institute of Forensic Medicine. Dr Baker said that a reasonable cause

Coroners Court (Amendment No. 1) Rules 2011

of death was ‘Blunt Head Injury’. A toxicology analysis was conducted which was

negative for substances.

Mr Williams was killed by Matthew Johnson who was incarcerated with Mr Williams at the time of his death. Mr Johnson was convicted and sentenced to the murder of the

deceased in the Supreme Court of Victoria on 8 December 2011.!

Following the finalisation of the criminal proceedings in the Supreme Court, the coronial

investigation was able to be resumed pursuant to the Coroners Act 2008 (the Act).

The Coroner’s Investigator, Detective Senior Sergeant Stuart Bailey, prepared an extensive brief of evidence (16 volumes), comprising a range of evidentiary material with witness statements, visual material, various Government and agency reviews and

reports as well as the criminal prosecution brief and prosecution material.

On 9 April 2014, after considering all the evidence including both written and oral submissions from representatives of Mr Williams’ family, the Chief Commissioner of Police, Corrections Victoria and the Office of Correctional Services Review [ decided, pursuant to section 52(6)(b) of the Act, not to hold an inquest into the death of Mr Williams. The decision was subsequently published and includes details of the various investigations conducted following Mr Williams death as well as the recommendations made following those investigations. I do not propose to revisit those matters in this

finding.

The immediate circumstances leading up to and including the actual death of Mr

Williams are however repeated below.

Supreme Court trial of Matthew Johnson

At the Supreme Court trial of Matthew Johnson, Justice Lasry described the

circumstances leading up to the murder as follows:

‘Williams had made two statements to police about the murder of Mr and Mrs Hodson.

The first was made in 2007. That statement was mainly to do with the corrupt relationship between Dale and Williams. In the second statement, made on 19 January

2009, Williams incriminated himself, Dale and Collins in the murder of the Hodsons.

' Reference: S CR 2010 195, Queen v M Johnson [2011] VSC 633

Coroners Court (Amendment No. 1) Rules 2011

He made a third statement on that same date which reflected him having listened to

some telephone intercept material.

The statements that Carl Williams made in January 2009 about the Hodson killings were based on discussions that he had with investigating police in late 2008. To facilitate those discussions, Carl Williams was taken away from the prison for some days. Asa result of his statements, charges of murder were laid against Paul Dale and Rodney

Collins.

He told his father, George Williams, that he had explained to [Johnson] that he was talking to investigators about police corruption. Carl Williams clearly wanted [Johnson] to believe that he was not going to give.evidence about other prisoners. He also told his father on a number of occasions prior to his death that he had been keeping [Johnson] informed of what he was doing with police, and it is clear to me that he did

that because he was concerned about how [Johnson] would respond.

From then until his death in April 2010, Williams spent a lot of time in [Johnson’s] company. How the prison authorities permitted that to happen is beyond me. No matter what [Johnson], Ivanovic or Carl Williams said or thought about his prison _ circumstances, on any view [Johnson was] a threat to his welfare as long as he was on

the record as a Crown witness against Dale and Collins.

On 28 February 2010, Williams was again removed from Barwon Prison for a short time to meet the prosecutors for the criminal proceedings for the case against Dale and Collins. He was described in the evidence as being hesitant about doing this and was worried about how it would be perceived by other prisoners and, in particular [Johnson’s] response. George Williams gave evidence that Carl Williams had again explained to [Johnson] what he was doing, and that he continued to be concerned about

leaving the prison.

In March 2010, several phone conversations in which [Johnson] participated recorded by prison authorities which demonstrate that [Johnson] had an interest in what was

happening with the committal proceedings against Dale and Collins...

On 5 March 2010, police provided Carl Williams with an electronic copy of the statements that he had made about the Hodson murders. On 6 March 2010, an electronic version of those statements was downloaded on to [Johnson’s] computer in

[his] cell...

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The records from [Johnson’s] computer illustrate that the last time [Johnson] accessed the statements made by Carl Williams was on 17 April 2010, two days before [Johnson]

murdered him. ..

The evidence also demonstrates ...that [Johnson was] either the leader, or a leader, ofa group of prisoners known as the ‘Prisoners of War’. One of the group’s important principles is the hatred of anyone, particularly any prisoner, who co-operates with police and informs against any person charged with criminal offences. Carl Williams knew about [Johnson’s] position in that group and his concern about [Johnson] knowing

that he was assisting police is entirely understandable in that context.

..J am satisfied that [Johnson] believed there was a realistic chance that Williams would give evidence in accordance with his second and third statement against both Dale and

Collins, and that [Johnson] could not be seen to sanction him doing so.

The coronial investigation and the brief of evidence

The Coronial brief of evidence noted the following circumstances of the death on 19

April 2010, including Mr Williams’ death as observed on CCTV.

On the 19" April 2010 the Herald Sun Newspaper published an article relating to the deceased and his former wife Roberta WILLIAMS. The article ran on the front page, and page four, and disclosed that taxpayers were to pay $8000 for the private school fees for the deceased's daughter, Dhakota; and $750,000.00 for a tax bill of his father George WILLIAMS. :

At 8.30am the deceased, IVWANOVIC and JOHNSON were all released from their cells

into a communal exercise room called the Day Room in Acacia Unit One.

At 8.50am the deceased contacted Detective Inspector Steve SMITH from the Victoria Police Taskforce who, at the time, was attending a training course and unable to take the call. Detective Inspector Steve SMITH sent an SMS to George WILLLIAMS stating that he would attend at the HM Prison Barwon to see the deceased on the Wednesday 21" April 2010.

At 9.00am the deceased rang Roberta WILLIAMS, Roberta WILLIAMS states:

e that they had a small disagreement on the phone about her going to an

appointment with a magazine when the deceased wanted to keep talking;

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° that the deceased seemed a bit agitated about something, but he did not mention

any problems.

At 9.20am the deceased rang his Barrister Shane TYRRELL in relation to the tax issue of his father George WILLIAMS. Shane TYRRELL states:

® that the deceased expressed concern that part of the original benefits for him giving information to the police was that the police would settle the tax debt of his father George WILLIAMS, This arrangement had fallen through for legal

reasons;

® that the deceased made no mention of any media articles, nor did he express any

concerns about JOHNSON or IVANOVIC;

« that the deceased was concerned about information being leaked to the media

even though it was suppressed.

At 9.26am the deceased rang his Solicitor Robert STARY in relation to the news article that was in the Herald Sun that morning. Robert STARY states:

° that the deceased sounded perfectly relaxed and did not seem terribly worried by the newspaper article, other than the impact it could have on his daughter and him;

° that a number of people were concerned about the deceased providing information to police, and that his movements outside the prison were seen as

special treatment.

At 9.40am the deceased rang a family friend...{She] states the deceased did not mention

that he was worried about anything.

At 10.10 am George WILLIAMS visited the deceased at HM Prison Barwon and remained with him until 11.50am. George WILLIAMS states that they spoke about general things, but mostly about the Herald Sun Newspaper article.

At 11.40am, after the visit with George WILLIAMS, the deceased was escorted back to Acacia Unit One. Prison Officer Brendan BUTLER states that the deceased showed no apparent concerns at that time.

Acting General Manager of the HM Prison Barwon Nick Selisky states that he was aware of the article in the Herald Sun Newspaper...on 19" April 2010.

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He asked the Operations Manger Gavin MARTIN to check with the deceased as to

whether any concerns existed. No concerns were passed onto the Prison Staff by the

deceased when approached and he is said to have appeared to be in good spirits.

The murder

The following events were captured on CCTV footage of the Day Room in Acacia Unit

One and clearly depict the events leading up to the deceased being murdered:

a

JOHNSON removes the seat and stem of an exercise bike (hereafter referred to as

the murder weapon) in the Day Room and secrets it in his individual cell;

JOHNSON then returns to the Day Room and sits down at a table with the deceased and IVANOVIC and has a conversation. There does not appear to be any animosity between the deceased, IVANOVIC and JOHNSON at this time;

the deceased, IVANOVIC and JOHNSON walk out to an external exercise yard of

Acacia Unit One and return;

the deceased sits down at a table in the Day Room with his back to the cell block of

the unit and continues to read a newspaper;

JOHNSON returns to his individual cell, covers the murder weapon with a white

towel and carries it into the individual cell belonging to IVANOVIC;

JOHNSON removes the white towel used to cover the murder weapon and takes the

towel to the laundry area; JOHNSON returns to IVANOVIC’S individual cell; JOHNSON exits IVANOVIC’s individual cell armed with the murder weapon;

JOHNSON approaches the deceased from behind while he is still sitting at the table reading the newspaper;

at 12.48pm JOHNSON strikes the deceased to the right side of his head with the murder weapon, knocking the deceased off his chair onto the ground, face first; JOHNSON then strikes the deceased with the murder weapon a further seven times

to the head area;

the accused takes the murder weapon to the laundry area of the Acacia Unit One;

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m. JOHNSON returns to the Day Room and places a white towel over the head of the

deceased, n. JOHNSON leaves the Day Room again;

  1. JOHNSON returns to the Day Room, approaches the deceased and dragged him by

his ankles into the deceased’s individual cell and closes the door;

p. JOHNSON then places a white towel over the pool of blood left where the deceased had been lying.

At about 12.54pm IVANOVIC uses the phone in Acacia Unit One to ring his sister..IVANOVIC informs her that he can’t talk for too long as something has happened, and that JOHNSON has just gone crazy ... IVANOVIC says that he thinks it

may be a murder, but he himself is safe.

At 12.58pm IVANOVIC uses the phone in Acacia Unit One to ring an associate... IVANOVIC informs him that the deceased is dead and that JOHNSON went crazy. [He] tells IVANOVIC to tell the Prison Officers and to help the deceased ...

JOHNSON and IVANOVIC then walk laps of the exercise yard and enter the Day Room several times until JOHNSON gains the attention of a Prison Officer.

At 1.15pm Prison Officer Suzette GAJIC states that whilst getting a trolley from the storage area adjoining the exercise yard of Acacia Unit One, JOHNSON and IVANOVIC approached her, JOHSNON tells her that she should press her button as the deceased had hit his head.

Prison Officer Suzette GAJIC raised the alarm and directed other Prison Staff to the area as she opened the gate, Several Prison Officers entered the Acacia Unit One and located the deceased in the individual cell, number 2, with extensive head injuries.

Both JOHNSON and IVANOVIC were calm at this time and advise the Prison Staff not

to let any female officers in.

At 1.16pm a ‘Code Black’ was called and the Emergency Control Centre was opened within the HM Prison Barwon. Prison Officers and nursing staff rendered medical

assistance to the deceased. Ambulance and police were notified.

JOHNSON and IVANOVIC were secured in separate cells and their clothing seized,

The deceased was unable to be revived and was pronounced dead shortly after the

ambulance officers attended.

Coroners Court (Amendment No. 1) Rules 2011

Findings

  1. Having considered all the evidence, I find that Carl Anthony ‘Williams born on 13 October 1970 died as a result of Blunt Head Injury on 19 April 2010 at the Acacia High Security

Unit, HM Prison Barwon in the circumstances outlined above.

  1. I find that Matthew Johnson caused the death of Mr Williams,

  2. I further find that Mr Williams was a person placed in care or custody as defined by section 3(1) of the Coroners Act 2008 immediately before his death.

COMMENTS Pursuant to section 67(3) of the Coroners Act 2008, I make the following comments connected

with the death:

  1. Section 7 of the Act provides that a coroner should avoid unnecessary duplication of inquiries and investigations, by liaising with other investigative authorities, official bodies

or statutory officers.

  1. After examining the breath of coronial material including other investigations and reviews’, I consider that the significant issues relevant to my investigation into Mr Williams’ death have already been the subject of extensive and comprehensive investigation or

investigations.

  1. In particular, I note that the Victorian Ombudsman prepared a comprehensive report which examined, amongst other matters, the placement of Mr Williams’ with Matthew Johnson, and the ongoing monitoring of that placement (The death of Mr Carl Williams at HM Barwon Prison — investigation into Corrections Victoria — April 2012). The Ombudsman made a total of 57 recommendations arising from Mr Williams’ death and I was advised that

55 of those recommendations had been endorsed as fully implemented or closed.

  1. In addition, I note that the Office. of Police Integrity* investigated matters relevant to the

Victoria Police Processes, management and adequacy of its processes and practices as

? Coronial investigation, criminal investigation, Victoria Police Driver Taskforce, Office of Correctional Service Review, Corrections Victoria, Ombudsman’s Victoria and the Office of Police Integrity.

3 As of 11 February 2013, the Office of Police Integrity functions were transferred to the Independent Broad-based Anti-corruption Commission.

Coroners Court (Amendment No. 1) Rules 2011

relevant to their management and handling of Carl Williams. This is a restricted report which was provided to me* and was considered as part of my investigation.

Pursuant to rule 64(3) of the Coroners Court Rules 2009, I order that this finding be published on the internet. ;

I direct that a copy of this finding be provided to the following: ’ e Mr George Williams and Ms Roberta Williams ° Spicer Lawyers on behalf of the family of the deceased © The Victorian Government Solicitors Office on behalf of the Chief Commissioner of Police

© Senior Sergeant Stuart Bailey, Coroner’s Investigator

Signature: pea.

JUDGE IAN GRAY

Date: S he A

  • Asa result ofa Supreme Court determination

Coroners Court (Amendment No. 1) Rules 2011

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