Finding into death of Neil Lawrence Williamson

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: COR 2015 1640

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1)

Section 67 of the Coroners Act 2008

Deceased:

Delivered on:

Delivered at:

Hearing date:

Findings of:

Counsel assisting the Coroner:

Representation

NEIL LAWRENCE WILLIAMSON

17 November 2016

Coroners Court of Victoria,

65 Kavanagh Street, Southbank

Inquest Hearing: 25 July 2016

Coroner Paresa Antoniadis SPANOS

Ms Sarah Gebert, Coroners Court In-house Solicitors Service

Ms A, mother of Neil Williamson, on her own behalf

Ms Elizabeth Tueno, instructed by Duffy & Simon Lawyers, for Ms Nicole Ferrari

Ms Natalie Blok, instructed by Norton Rose Fulbright, for the Chief Commissioner of Police

Page |

I, PARESA ANTONIADIS SPANOS, Coroner,

having investigated the death of NEIL LAWRENCE WILLIAMSON

and having held an inquest in relation to this death on 1 July 2016

at Melbourne

find that the identity of the deceased was NEIL LAWRENCE WILLIAMSON born on 21 March 1980

and that the death occurred on 4 April 2015

at the Ravenswood rest stop, Calder Freeway, Ravenswood, Victoria

from:

1 (a) INTRAORAL SHOTGUN WOUND

in the following circumstances:

Neil Lawrence Williamson, aged 35 years, resided in Bayles with his de facto partner, Nicole Ferrari at the time of his death. Mr Williamson was born in Robinvale and was the son of Ms

A and Barry Williamson, who separated when he was young,

Mr Williamson was of Aboriginal descent through Ms A and had three siblings, Paul, James and Natalie, who also shared the same mother. He also had an older sister, Kylie Lawry, on

his father’s side.

Mr Williamson was the father of Roman Joynt-Williamson born on 27 January 2014, whose

mother is Sariah Joynt.

Ms Ferrari was pregnant at the time of Mr Williamson’s death and his child was born

subsequent to his death.

Mr Williamson appeared to have been very well liked with many close supportive friends. He had previously worked with aged care providers through the Rumbalara Aboriginal Co-op in

Swan Hill and as an Information Technology assistant with the Australian Grand Prix.

Mr Williamson suffered ongoing pain caused by arthritis and gout as well as long term

depression!

' Medical Records, Coronial Brief (CB) at p. 873.

On the evening of 4 April 2015, Mr Williamson contacted a friend and advised him that he was near a forest area” in a hire vehicle and intended to kill himself with a shotgun. He had

also threatened suicide in the past few days.

The police eventually located Mr Williamson and followed him over a distance of about 80 kilometres whilst attempting to negotiate his surrender. Mr Williamson eventually agreed to pull into the Ravenswood rest stop on the Calder Freeway where he shot himself, prior to any

further interactions with the police.

Purposes of the Coronial Investigation

The primary purpose of a coronial investigation into a reportable death® is to ascertain, if possible, the identity of the deceased person, the cause of death (interpreted as the medical cause of death) and the circumstances in which the death occurred.* An investigation is conducted pursuant to the Coroners Act 2008 (the Act). The practice is to refer to the medical cause of death incorporating, where appropriate, the mode or mechanism of death, and to limit

the investigation to circumstances sufficiently proximate and causally relevant to the death.

Coroners are also empowered to report to the Attorney-General on a death they have investigated; the power to comment on any matter connected with the death, including matters relating to public health and safety or the administration of justice; and the power to make recommendations to any Minister, public statutory or entity on any matter connected with the death, including recommendations relating to public health and safety or the administration of justice. Sections 72(1), 72(2) and 67(3) of the Act regarding reports, recommendations and

comments respectively.

Standard of proof

Wl.

Coronial findings must be made on the basis of proof of relevant facts on the balance of

probabilities and subject to the principles enunciated in Briginshaw v Briginshaw*.

THE EVIDENCE

Detective Acting Sergeant Leigh Howse was the Coroner’s Investigator (CI) and prepared a detailed and comprehensive Coronial Brief. His investigation was oversighted by Professional Standards Command (PSC), in accordance with the Victoria Police Oversight Principles. I note that a member of PSC was present during the statements of the police officers involved

in the incident.

? The 000 operator determined from the information that he was likely to be in the Bullengarook area.

• Section 4 of the Act requires certain deaths to be reported to the coroner for investigation.

• Section 67 of the Act.

• (1938) 60 C.L.R. 336 especially at 362 — 363.

My finding is based on the evidence contained in the Coronial Brief as well as the evidence

presented at the inquest and any documents tendered at that time.

INQUEST

Prior to the commencement of the inquest, it was apparent that many facts about Mr Williamson’s death were known and were not in dispute. This included his identity, the

medical cause of his death and most of the circumstances surrounding his death.

However, given that police were attempting to arrest Mr Williamson under s351 of the Mental Health Act 2014 immediately prior to his death, the Act required that I convene an inquest as

part of my investigation.

I also conducted two directions hearings inthis matter® to allow interested parties to raise issues with respect to Mr Williamson’s death, which were properly within the ambit of my

investigative powers and proximate to his death.

In particular, Ms Ferrari raised the issue of whether it was appropriate to block the exit of the Ravenswood rest stop, so that Mr Williamson was effectively prevented from leaving the

stop. I considered this matter an appropriate issue to be investigated further.

1 also determined that it was appropriate to hear from the Cl as well as Senior Sergeant Darren McQueen, who provided a statement additional to the Coronial Brief. This statement primarily addressed issues concerning the engagement of a Critical Incident Response Team

(CIRT) negotiator, as one had not been sought in relation to this incident.

Medical Examination

19,

21,

A post-mortem examination was conducted by Dr Jacqueline Lee, Forensic Pathologist of the Victorian Institute of Forensic Medicine, who determined the cause of death to be ‘Intraoral

Shotgun Wound’.

No other injuries other than those associated with the shotgun wound were found on Mr

Williamson’s body.

The toxicological report showed ethanol (alcohol) at a concentration of ~0.10 g/100mL in post-mortem blood, and at a concentration of ~0.12 g/100mL in vitreous humour (considered more stable and a better indicator of ante-mortem concentrations) and paracetamol at ~ 1.5

mg/L but no other commonly encountered drugs or poisons.

® 30 March and 27 May 2016.

Circumstances leading to death

23,

On 29 March 2015, Mr Williamson asked his landlord if he could arrange to borrow a gun from one of his employees to shoot a few magpies. He had borrowed a gun in the past in similar circumstances without incident. Mr Williamson said that he had a licence’ and always locked the firearm away in an appropriate manner on its return. His landlord said he was too busy to make the arrangement and told him to make the request himself, which he did by text.

The gun was subsequently placed in a shed on 31 March after which Mr Williamson shortened the barrel.

On 30 March, Mr Williamson made a will, where he appointed his friend, Shane Clue to be

the executor and trustee of his estate.

On the morning of 31 March, Mr Williamson made various video messages which contained goodbye messages and instructions on his death. He said, ‘/’// be getting a hire car — going doing the job, Fingers crossed it turns out fuckin’ how I’ve planned it for last fuckin’ couple of months....God, giving up the world, wouldn't believe the weights that on my shoulders right now, as much as I've prepared for it, it’s just not right...1 just hope it all goes to plan properly...'. He noted that he had debts of about $50,000, which appear to have included debts to the Commonwealth Bank of Australia ($11,567.81), GO ($5,502.36) and Credit Corp Group ($13, 035.71).

According to his partner, in March 2015 Mr Williamson’s mood had changed and he became

like a hermit, spending all his time playing X-Box in their bedroom.

At about 1.44pm on 31 March, Mr Williamson hired a vehicle in Pakenham (silver Holden Captiva, registration 1CS3K W), after which he delivered disks containing sexually explicit material involving Ms Joynt to a number of people. The evidence suggest that they had an acrimonious break-up and he was the subject of an intervention order taken out by Ms Joynt at the Werribee Magistrates’ Court on 18 September 2014. The order was however unserved.

Part of Ms Joynt’s application for an intervention order included a claim that Mr Williamson had threatened to distribute sexually explicit material involving her to her employers and

others.

Sometime between about 3.23pm on 31 March and about 2.00am the following morning, Mr Williamson appears to have been in the Point Cook area where Ms Joynt and their son

resided. He called friends from outside her home describing his intentions. One version

7 Mr Williamson was a person who was prohibited from holding a firearm licence due to his County Court conviction on 4 November 2011 and the intervention order made at the Werribee Magistrates’ Court on 18 September 2014.

29,

involved him shooting Ms Joynt and their son with a sawn off shot gun and then killing

himself. He said that he wanted to cause Ms Joynt pain for not allowing him to see his son.

At about 2.00pm on 1 April Mr Williamson contacted his friend, Mr Clue, saying he was

drunk, in a forest and was going to shoot himself.

The evidence suggests that over the next few days, Mr Clue had numerous conversations with

Mr Williamson and he came and stayed with him and his partner in Tresco.

Mr Williamson visited other friends including Alex Green and Angelo Marra on 2 April. His friends urged him to seek medical assistance. He did however return to Mr Clue’s home on 3 April. Mr Clue said that he thought he had talked Mr Williamson through his depressive episode, as he had many times before, but Mr Williamson left the following morning and that

was the last time Mr Clue saw him.®

4 April 2015

33:

At about 8.15pm on 4 April 2015, Mr Clue contacted 000 to report that he had received a call at approximately 8.10pm from Mr Williamson who said that he was suicidal, with a gun and was travelling in a hired vehicle in the Wombat State Forest. He said that he had also consumed a bottle of scotch. Mr Williamson asked him to call 000 as he did not want a ‘random’ person to find him. Mr Clue related that his friend was depressed and had been suicidal in the preceding days. The operator worked through Mr Williamson’s possible

location and determined that he might be in the Bullengarook area.

At about 8.30pm, police were notified by the operator that there was a suicidal male in possession of a sawn-off shotgun driving a hired silver coloured Holden Captiva in the

Bullengarook area.

Senior Constable Anita Sidorovska (observer) and Constable Daniel Bolger (driver) (with call sign Gisborne 303), responded and started patrolling in order to locate Mr Williamson. S/C Sidorovska contacted Mr Clue to discuss his complaint further. Mr Williamson had told Mr Clue that he would put a gun in his mouth and end it. However, Mr Clue was unable to

confirm that he had seen him possession of a gun.

At 8.47pm (and after two failed attempts), S/C Sidorovska spoke to Mr Williamson who said that he wanted to commit suicide and that ‘/’m feeling really bad to be honest, I’ve done something really bad and it’s not my fault.” Mr Williamson said that he was driving along

the Bullengarook-Bacchus Road heading towards Werribee. He was evasive about what he

• Mr Williamson said that Mr Clue had prolonged his life by about 10 years.

° Statement of Anita Sidorovska, CB at p. 303.

39,

had done and whether he had a gun. S/C Sidorovska said that he agreed to talk with her face

to face and then hung up.

Gisborne 303 continued to patrol and again called Mr Clue who was on the phone to Mr Williamson at that time. During that call and, at about 9.20pm, the members saw a silver coloured Holden Captiva drive eastbound towards Gisborne. They were stationary at the intersection of Carrolls Lane and Bacchus Marsh-Bullengarook Road when they made the observation. They activated first their lights and then sirens in an attempt to intercept the vehicle, but it did not stop. The officers were convinced that it was Mr Williamson’s vehicle

as the registration was listed as a hire vehicle.

Gisborne 303 communicated their observations on the police radio, including that Mr Williamson was travelling within the speed limit, that he possibly had a firearm and that they

were not in pursuit but were keeping the vehicle under observation.

At about 9.30pm, the police followed Mr Williamson’s vehicle past the Gisborne Police Station, left into Aitken Street and left onto the Calder Freeway. At this time Gisborne 303

did not have lights or sirens activated and Mr Williamson was observing all the road rules.

On the Calder Freeway, two Macedon Ranges highway patrol units, both fitted with in-carvideos eventually took position behind Mr Williamson’s vehicle. They were Macedon Ranges 611 with Leading Senior Constable Wall (in a marked vehicle) and Macedon Ranges 630 with Leading Senior Constable Tepper (in an unmarked vehicle), Macedon Ranges 611 was positioned in the right hand lane and Macedon Ranges 630 was positioned in the left hand lane. They were positioned in this manner to prevent other road users from driving past Mr Williamson’s vehicle.'° Gisborne 303 and Woodend 253 (later), with Sergeant David Jakobi, were also behind. Sgt Jakobi was in a position to provide supervision while on scene.

There were no lights and sirens from any police vehicle. Other police vehicles, were at times

part of this convoy behind Mr Williamson’s vehicle.

Sergeant Scott Murray, who was located at the Gisborne Police Station, was contacted by Mr Williamson who said to him, ‘/’m driving the car that you [sic] divvy van is following at the moment.’'' With reference to the Highway Patrol Units following Mr Williamson, Sgt Murray said, ‘I told Neil that the Highway Unit was not going to intercept him as he had requested but that they would continue to follow him in order to ensure the safety of other people on the

road at the time. Neil said that he understood and that was fine.”

19 | note that vehicles sometimes moved to different positions as required, including to block exits.

" Statement of Sgt Murray, CB at p. 335.

2 Statement of Sgt Murray, CB at p. 337.

44,

They discussed options around his surrender over many conversations that evening, Mr Williamson told Sgt Murray on a number of occasions that he would pull over in the next five minutes, but wanted to clear his mind. Mr Williamson was made aware that he would be

arrested under section 351 of the Mental Health Act 2014 due to his behaviour.

Mr Williamson told Sgt Murray that he had a loaded double barrel shotgun sitting between his legs but was not going to use it. At one point, he also disclosed that he had gone around to Ms Joynt’s house to ‘blow her head off her shoulders.’'? Sgt Murray also thought that he

sounded substance affected.

Sgt Robin Short (call sign WKY 251) was the incident/pursuit controller who instructed all units over the airways not to actively engage in a pursuit, which meant there would be no lights/sirens. I note that Senior Sergeant Craig Gaffee (with call sign Bendigo 265), was performing Divisional Supervisor duties for the Western Region Division 5 and monitored the

incident from about 9.50pm.

The Airwing was deployed and stop sticks were considered, but were discounted as the police

said that they did not want to inflame the situation.

As the police ‘convoy’ progressed, arrangements were made for different units to sit at off ramps and on the freeway to prevent Mr Williamson’s vehicle from exiting the freeway. It was apparent that the police were particularly concerned that he was armed and would enter a

populated area, such as Bendigo (particularly due to Easter).

Sgt Murray spoke with Mr Williamson for significant periods of time, during which Mr Williamson cut the call off to make contact with friends, including Mr Clue, Alex Green, Kevin Donnelly, Quentin Graham and Angelo Marra. I note that one conversation between

Sgt Murray and Mr Williamson lasted for 25 minutes [10.04pm and 10.13pm].

At around the Elphinstone area, Mr Williamson slowed his vehicle down from 80km/h to around 40km/h, travelling in the emergency lane. He varied between having the left hand

indicator on, to having the hazard lights on, to not have any signal activated at all,

As Mr Williamson was getting closer to Bendigo, the police decided that they should try to get him to pull over. The Ravenswood rest stop, which is located approximately 20

kilometres from Bendigo, was selected as an appropriate site.

'S Statement of Sgt Murray, CB at p. 340.

49,

Si.

A security sweep of the truck stop and neighbouring Caltex service station was conducted by police and it was declared clear of civilians. An officer also positioned a vehicle to block

access to the service station and an ambulance was also arranged to be available.

The instructions given to Mr Williamson, when he pulled over, was to show his hands outside

the driver’s side window and open the car door from the outside.

Mr Williamson advised Sgt Murray that he would comply with his request and stop at the Ravenswood rest stop. “Neil said that the police could let people drive past him now because he was well over into the emergency lane and that he did not want to hold everybody up. I explained to Neil that no one would be coming past him as we wanted to keep everybody,

including him, safe. Neil said ‘Fair enough what do you want me to do?’’"'*

After providing the surrender instructions to Mr Williamson, Sgt Murray said, ‘J asked Neil if he was still prepared to pull over into the truck stop and he said ‘Yep, I’m just going to ring me mate first’ and then hung up. Neil further added that he promised that he would not do anything stupid because I had been really good to him and that he would not put me through

that. !°

At about 10.45pm, Mr Williamson exited at the Ravenswood rest stop and came to a stop in an area near the public toilets. The two Macedon Ranges TMU vehicles stopped side by side a distance behind the Holden Captiva, as planned. This can be viewed on the in-car video.

The distance over which the police followed Mr Williamson was 88 kms.

A gunshot was thought to be heard, after which the police found Mr Williamson in his vehicle

deceased, with a gun placed between his legs.

History of Sexual Assault

BE

Mr Williamson spoke to close friends and health professionals about the fact that he was abused by an older male cousin from when he was 6 years old and ‘forced’ to engage in sexual acts with his younger cousin (‘was threatened with physical abuse if he did not

comply’'*), probably starting when she was 4-5 years old (and he was 5-6 years older).

It is clear from the evidence in the Coronial Brief (including medical records, his video diary and his own words to friends) that these matters affected his life and were an enormous

contributor to the depression he suffered.

'4 Statement of Sgt Murray, CB at p. 342.

'S Statement of Sgt Murray, CB at p. 343.

'© Statement of Shane Clue, CB at p. 133.

In the words of his close friend Mr Clue - ‘The sexual abuse that Neil suffered throughout his childhood was the major issue that affected Neil throughout his adult life and was a major

cause of his depression and mental health issues. ’"”

Mr Williamson was charged with criminal offences (sexual penetration of a child) relating to his cousin on 15 October 2007 (5 charges) which dated back to between 1993 and 1996 (when he was between 13 and 16 years). On 4 November 2011 in the County Court, he pleaded guilty to one count of indecent act with a child under 16 years (although he complained to his friends that he shouldn’t have pleaded guilty). He was sentenced to 12 months imprisonment

which was suspended for 12 months.

Close friends noted that Mr Williamson changed after being interviewed by police in 2007.

‘The allegations affected Neil greatly in that he was unable to continue his role with the aboriginal aged care community. This took Neil’s livelihood away from him and he had no

way of supporting himself. ’'®

Mr Williamson told his friends during this time that he would kill himself. He also told the victim: ‘I've gotta live every day thinkin’ that I’ve done the worst thing possible on this planet’. Despite these words, he still appears to have held a grudge against the victim for taking the matter to the police and blamed the original sexual abuse that he suffered for what

happened.

Mr Williamson’s doctor said that he was angry about what had happened, particularly in relation to the way he had been drawn into the activity, but also with his family for allowing it to happen. Mr Williamson reported that he dreamed incessantly of doing violence to his

family and the people who had been guilty of perpetrating the assaults on him.

Victoria Police Response

Pursuit

Although police vehicles did not overtly and actively engage in a pursuit with Mr Williamson, the actions of the police on the night are still regarded as a pursuit according to Victoria

Police policy.

Pursuant to that policy, the driver of Gisborne 303 was not permitted to engage in a pursuit as he had a restricted driving authority. The driver said that he did not think he was engaged in a pursuit at the time, noting that there was no speed, lights or sirens involved. This matter was

not disputed by police and was highlighted in their internal review. Given these matters and

'7 Statement of Shane Clue, CB at p. 133.

'8 Statement of Alex Green, CB at p. 165 -166.

the circumstances of this case, I do not consider it to be an issue that would have affected the

outcome in relation to Mr Williamson or that it requires further comment.

Non-testing of members

I note that no drug or alcohol testing of the police members involved in this matter was conducted. The evidence suggest that three attempts were made to get the testing done, but Victoria Police were unable to raise their service provider.!’ Drug testing is required following a critical incident in accordance with Victoria Police policy”. Again this is a matter that was not disputed by police. It is unfortunate that testing of the members did not occur given that this process benefits both the police involved and the community in terms of the transparency of the investigation, but again there is no evidence to suggest that it would have

affected the outcome for Mr Williamson or the overall investigation into his death.

Engagement of CIRT negotiator

It was initially unclear whether a CIRT negotiator should have been engaged to talk to Mr Williamson that evening. To assist me in this regard, I sought a statement from the Chief Commissioner of Police (CCP) regarding the ‘rules’ governing when and in what circumstances a CIRT negotiator is engaged; what different or additional skills or techniques a CIRT negotiator might have brought to the incident and whether the relevant Victoria Police rules and guidelines (with respect to the engagement of a CIRT negotiator) were complied

with in the circumstances of this case.

S/Sgt McQueen, who is attached to CIRT, provided a statement on behalf of the CCP which

addressed those issues and, in particular, I note his evidence that:

a. the relevant Victoria Police policy says that the use of a CIRT negotiator is only suggested in situations where the situation is beyond the scope, experience and skill level of general duties police (Developing situations: - where persons are threatening suicide and intervention is beyond the scope, experience and skill level of general duties police”');

b. in the circumstances of this case, it was not beyond the scope of the negotiator who

undertook negotiations with Mr Williamson;

'9 The Cl said: ‘Twas subsequently informed that the person that was on call on the night didn't realise that they were on call and subsequently had their phone either off or on silent and therefore wasn't contactable.’ Transcript at p. 20.

20 VPMG —Testing members for Alcohol and Drugs of Dependence.

2! VPMG — Specialist Support, CB at p. 1288.

69,

the negotiations that took place appeared to be consistent with the practices set out for

CIRT negotiators; and

even if CIRT assistance had been sought on that night, they would not have assumed the role of primary negotiator as the negotiator had already established a good rapport with

Mr Williamson.

S/Sgt McQueen said when asked how he assessed that the task of negotiating with Mr Neil Williamson was not beyond the scope, experience and skill level of the general duties police

engaging with him on that night:

‘On reading the statements provided, it was clearly apparent that Sergeant Murray had gone through a number of steps or the first two steps of the stages of negotiation. He'd built up what I would say is very good rapport with Mr Williamson. He was getting meaningful compliance from Mr Williamson and it would appear that they were moving - well, in fact had moved into stage 3 of the surrender plan. Just further to that, there was - there was good support from other police members, police units providing the escort. There was no further danger particularly in the manner of his driving and until the point where the vehicle had come to a complete stop or for example if Mr Williamson had gone into a premises or similar, CIRT don't provide any support to mobile intercepts. That's not part of our

capability, 7?

He further clarified that CIRT would not have got involved in any type of pursuit and only verbal support would have been provided to Sgt Murray, had it been sought. (‘J would have got my negotiator unit to make direct contact with Gisborne and speak to Sergeant Murray.’)

Counsel for Ms Ferrari submitted that CIRT should have at least been considered,?3

After considering all the evidence, there is no basis to conclude that CIRT was either required to be utilised (as dictated by policy or the circumstances as they arose) or that CIRT involvement would have been anything other than verbal support (unless the situation turned

into a siege) or that their engagement would have made a difference to the outcome.24

Of the discussions with the negotiator on that night Mr Clue related,

2 Transcript p. 34

?3 Counsel for Ms Ferrari said that ‘it's the lack of evidence that points to the fact that these members did or didn't have the necessary skills to handle that situation.’

*4 Reference was made to the VPM — Policy Rules, Emergency management response, and that an incident such as this would be referred to as an emergency (although not a Class 1, Class 2 or Major Emergency) for which an emergency management response is required. The Rules say that the Incident Command and Control System (ICCS) should always be applied and J note that the Victoria Police Debrief Report (Exhibit 35) suggests that this system was appropriately utilised in this case. CB at p. 1177.

‘Neil eventually rang back and said that he had been speaking to the police and that he was going to pull over and give himself up. Neil said that he was very happy with the police officer that he had been speaking to and called him a bloody legend. Neil said that he was was a challenge and that he couldn't go on suffering any longer. Also there were no amount of words that any person could say that would change his mind and that he was going to end

his life one way or another one day. ?°

Blocking of the truck stop exit

vad

72,

74,

I note that there was a specific plan to block the exit of the Ravenswood rest stop and this decision was made by Sgt Short (‘Kyneton 251...And also would like a unit at the exit of that truck stop in case he drives straight through it?®). At the time this decision was made the police had managed to contain the situation over a considerable distance, which included preventing Mr Williamson from entering populated areas. However, as he was approaching

Bendigo, the agreed plan was that he be prevented, if possible, from entering that location.

The broad risks over the period of the interaction with Mr Williamson were considerable.

They included him stopping on the highway, driving erratically or using the firearm. There were risks to Mr Williamson, members of the public and the police. ‘...if he's in a vehicle...you've got a mobile situation so it's very fluid, you can't control that. There's - it's difficult to obviously stop that vehicle. There's a risk of the vehicle being driven into a populated area. As far as engagement if it does stop, there's - there's great risk in

approaching the vehicle with a person armed with the firearm’ ?"

It was submitted on behalf of Ms Ferrari that Mr Williamson should have been advised that the exit to the rest stop was to be blocked so that he wasn't caught by surprise and didn't react

unpredictably.

The evidence suggests however that Mr Williamson was aware of multiple police vehicles around him, and that on a number of occasions throughout the pursuit, police vehicles travelled past him to block other exits, or other police vehicles were already positioned at exits in preparation for his passage. Mr Williamson also acknowledged his awareness of the

police needing to keep everybody safe.

In my view the blocking of the exit was reasonable given the multiple risks involved in this

matter and for the effective execution of the plan to prevent him from entering Bendigo. In

25 Statement of Shane Clue, CB at p. 148-9.

26 Police Radio Communications, CB at p. 559.

27 Transcript p. 43.

addition, not advising Mr Williamson that the exit would be blocked was open as a tactical decision in all the circumstances. Having said that, I doubt that it would have been a surprise

to Mr Williamson, who seemed to be acutely aware of what was happening around him.

It is also possible that Mr Williamson had likely made his mind up well before the rest stop (and his awareness that the exit was blocked), that he was not going to give himself up. ‘The last time on the Saturday evening that we heard from Neil was at about 10.45pm. Shane relayed to me that Neil said he was about two kilometres away from a truck stop and the police had asked him to pull over there. Shane asked him if Neil was going to let them help him get the things he needed and Neil said yes. Things went quiet and Neil basically said his

goodbyes and that he was not going to give himself up, this was relayed to me by Shane.’

Mental Health Act

7%.

Ms A was concerned that her son may have reacted badly to being advised that he would be arrested under the Mental Health Act and said that the prospect of jail would have been preferable to him. Whilst I understand her concern, it is appropriate to advise people of the powers proposed to be utilised when detaining them and it appears that the information related to him was that he would receive the treatment and assistance he required. ‘Neil said that the police said that they would take him to a hospital and would get him the help that he needed.”° In my view, there is no basis to conclude that Mr Williamson would not have

understood the terms under which he would be dealt with, if he had surrendered.

No recording of Aboriginality in LEAP records

It was clear when the police were interacting with Mr Williamson that they were not aware that he was an Aboriginal man. It was not noted in his LEAP records and Mr Williamson did

not advise police of this fact.

I was advised that a person’s status as an Aboriginal person is recorded on the LEAP database only where that person self identifies, unless there are circumstances where it may be obvious.

Ms A indicated that the Swan Hill police were well aware that her son was Aboriginal and this should have been noted when he was being interviewed concerning the sexual assault

offences.

Ms A noted that her son ‘was a young, proud, Aboriginal man, he would never not identify’ as

such.*?

8 Statement of Tegan McCoy, CB at p. 159.

»° Statement of Shane Clue, CB at p. 148-9.

3° Transcript p. 30.

It is not apparent why his police records did not indicate that he was Aboriginal although I do note that he had very few interactions with police. In the context of my investigation, ] am unable to resolve why it was not recorded in the LEAP database or how this matter may have

affected the circumstances of Mr Williamson’s death.

Lack of cultural training regarding negotiators and Aboriginal negotiators

Ms A raised concerns regarding the fact that there were no Aboriginal negotiators and there

appeared to be a lack of cultural training with existing negotiators.

In the circumstances of this case, as already noted, the police were not aware that Mr Williamson was an Aboriginal person and Mr Williamson did not at any time raise this matter

in his dealings with police.

This issue is therefore speculative as there was no basis for the police to have been aware of Mr Williamson’s Aboriginality, and if an Aboriginal negotiator had been engaged, whether

that would have been helpful.

In addition, and in any event, I heard evidence that no such Aboriginal negotiators exist in Victoria. I also evidence that whilst there might be some cultural training for negotiators in

Victoria, there was none specific for Aboriginal people.

In the context of this case, it appears that Mr Williamson was in contact with many of his close friends on that evening, that he was not constrained in terms of who he could contact or

that he was seeking to talk to any other person.

Ms A indicated her intention to write to the CCP about the need for Aboriginal negotiators

quite apart from the outcome of the coronial investigation of her son’s death.

Complaints about post death issues

Delayed release of Mr Williamson’s body

Ms A complained that there had been a one month delay before the body of her son was released. I investigated this matter and was able to establish that Mr Williamson’s body was admitted to the care of the Coronial Admissions and Enquiries service provided by the Victorian Institute of Forensic Medicine on behalf of the Coroners Court of Victoria on Sunday 5 April 2015 and was released to Mr Clue as his executor/senior next of kin on Friday 24 April 2015 some 19 days later. I note that due to the extent of facial trauma, Mr

Williamson’s body was not considered suitable for visual identification and had to be

identified by DNA sampling, which is a factor that can delay the release of a body by some days.7!

No statements taken from Ms A and her family

91,

Ms A complained that she and her family had not provided statements for the Coronial Brief which meant that their views on his history and life were not recorded. In particular, Ms A

noted that she had provided financial support to Neil for his court case.

The CI gave evidence that he had on a number of occasions asked for a statement from Ms A and it was his usual practice for this to occur at a location that was suitable to the interviewee.

Ms A was of the view that the statement must be taken at a police station and she was not

prepared for this to occur.

This was an unfortunate misunderstanding which appears to have caused unnecessary anguish

for Ms A in the context of this investigation.

Mr Williamson’s grandmother

O2:

Mr Williamson’s grandmother, who attended the inquest made the following comments about

her grandson:

Yeah, he's always been with us and worried about us all and he's helped everybody all the time, on his big jobs that he's had and age and disability, he helped people, young people, you

know with the teenagers and all these good things he used to do, you know. Back and

forwards to Melbourne driving cars. ... make him go one day there and back and things like

that and he got on well with everybody. And I'd seen ....the good things because he never

done anything wrong in front of me.’

Findings

Having considered all the evidence, I find that Neil Lawrence Williamson, born on 21 March 1980, died as a result of a self-inflicted gunshot wound on 4 April 2015 at Ravenswood rest stop on the Calder Freeway, Ravenswood, in the circumstances outlined above. I further find that Mr Williamson intentionally took his own life and had prepared to do so since 31 March

2015 at least, and possibly longer.

It is not possible to determine on the basis of the available evidence whether Mr Williamson actually vacilliated in his resolve to take his own life during his engagement with the police

on the night of 4 April 2015 or whether he was saying what he thought the police wanted to

31 Also relevant to the delay complained of is the fact that Mr Williamson died during the Easter public holiday period, that the Authority to Release Mr Williamson’s body to funeral directors on behalf of Mr Clue as his Executor was dated 20 April 2015 and the DNA comparison analysis report was dated 22 April 2015.

hear. It is certainly possible that Mr Williamson had been talked around at various stages and

equally possible that he was resolved to end his life as planned.

95. The available evidence supports a finding that the police involved with Mr Williamson in the hours immediately preceding his death conducted themselves in a professional manner and took all reasonable and appropriate steps to protect Mr Williamson from himself and to

protect the public at large from Mr Williamson.

96. Pursuant to section 73(1) of the Coroners Act 2008, I order that this Finding be published on

the Court’s website.

I direct that a copy of this finding be provided to the following: e Ms A, mother of Neil Williamson e Mr Shane Clue e Duffy & Simon Lawyers on behalf of Ms Nicole Ferrari e Norton Rose Fulbright on behalf of the Chief Commissioner of Police

e Sergeant Leigh Howse, Coronial Investigator

Signature:

“Pps

PARESA ANTONIADIS SPANOS Coroner Date: 18 November 2016