Finding into death of Glenn Albert Sanders

IN THE CORONERS COURT

OF VICTORIA AT WARRNAMBOOL Court Reference: COR 2014 1884

FINDING INTO DEATH WITH INQUEST Form 37 Rule 60(1) Section 67 of the Coroners Act 2008 Findings of: MR JOHN OLLE, CORONER Deceased: GLENN ALBERT SANDERS Delivered On: 24 OCTOBER 2017 Delivered At: THE CORONERS COURT OF VICTORIA,

65 KAVANAGH STREET, SOUTHBANK Hearing Dates: 26 — 30 JUNE 2017

Counsel Assisting the Coroner: MS NAOMI HODGSON OF COUNSEL

INSTRUCTED BY MS JESSICA WILBY, PRINCIPAL IN-HOUSE SOLICITOR

Representation: MR RON GIPP FOR THE CHIEF COMMISIONER

OF POLICE, INSTRUCTED BY VGSO

MS DEBORAH FOY FOR SOUTH WEST HEALTHCARE, INSTRUCTED BY HEALTHLEGAL

MR JONATHAN GOETZ FOR VICTORIAN WORKCOVER AUTHORITY, INSTRUCTED BY WORKSAFE

I, JOHN OLLE, Coroner, having investigated the death of GLENN ALBERT SANDERS

AND having held an inquest in relation to this death on 26 — 30 June 2017

at the Coroners Court of Victoria at Warrnambool

find that the identity of the deceased was GLENN ALBERT SANDERS born on 25 November 1965

and the death occurred on 12 April 2014

at 1370 Hamilton Highway, Derrinallum, 3325:

from:

l(a) INJURIES SUSTAINED IN AN EXPLOSION.

in the following circumstances:

BACKGROUND

Glenn Albert Sanders (Glenn) was aged 48 years at the time of his death. He lived on his family property at 1370 Hamilton Highway, Derrinallum (‘the farm’). His mother ordinarily resided in a separate house on the farm, however, was an inpatient at the St John of God

Hospital in Ballarat at the time of his death.

On Friday 11 April 2014 at approximately 6:50pm, a team of members from the Victoria Police Special Operations Group (SOG) together with two trained negotiators from the Victoria Police Critical Incident Response Team (CIRT) attended the farm. Their purpose was to take Glenn into custody following allegations he had falsely imprisoned and assaulted a local resident at the farm the previous day. Attending police were in possession of intelligence indicating that Glenn was likely to be wearing an Improvised Explosive Device (IED) on his body and that the farm was ‘potentially booby trapped with explosives’. Accordingly, Glenn’s

arrest was considered an extremely high risk arrest situation.

On arrival, SOG command placed a perimeter around the farm. An armoured vehicle known as a Bearcat was driven down the driveway and positioned a short distance from Glenn’s house. An SOG member inside the Bearcat called upon Glenn to show himself. Glenn was observed outside his house on the eastern side. However he moved inside his house for a short

time before returning outside in the vicinity of the Bearcat.

Senior Constable Sykes, was the first negotiator in attendance. He had received a SOG briefing, and had Glenn’s LEAP dossier. His goal was to ascertain whether Glenn was wearing an IED, and encourage him to submit peacefully. Glenn complied with the request to remove clothing, revealing he was wearing an IED on his upper body, which consisted of detonation cord and initiation switches. Negotiations were undertaken for a number of hours.

Though a first name rapport was achieved between Glenn and his negotiators, during which Glenn provided repeated assurance he did not want to hurt any police member, he steadfastly refused to remove the IED. At approximately 1:20am, whilst Glenn was talking to the second negotiator Sergeant Chandler, a massive explosion occurred behind Glenn. Within seconds of the first explosion, Glenn’s IED detonated, followed by a series of smaller explosions. Glenn was killed instantly. The first explosion razed Glenn’s house. In addition, three other large structures on the farm were also subsequently leveled, and Glenn’s mother’s house was severely damaged. Two SOG members (Operators 122 and 135) were injured. Operator 135

sustained life threatening injuries.

It is likely that Glenn had previously rigged his house and 3 other large structures on the farm with explosives, which he had connected to a timer device. Upon the arrival of police, it would appear Glenn activated the timer in his house, for 1.20am. The first explosion set off a series of explosions around his house and 3 large structures on the farm, which appear to have been linked via conduits containing detonation cord running underground. In addition to the initial massive explosion, and the detonation of Glenn’s IED, there were a 6 separate blast

sites around the house and within structures on the farm.

PURPOSES OF A CORONIAL INVESTIGATION

Reportable death1 requires certain deaths to be reported to the coroner for investigation. Apart from a jurisdiction nexus with the state of Victoria, the definition of a reportable death includes all deaths that appear “to have been unexpected, unnatural or violent or to have resulted, directly or indirectly, from accident or injury.” The purpose of a coronial investigation is to independently investigate a reportable death to ascertain, if possible, the identity of the deceased person, the cause of death and the circumstances in which the death oceurred.? 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.

' Section 4 of the Act 2 Section 67 of the Act

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 a 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’ regarding reports, recommendations and comments respectively.

The focus of a coronial investigation is to determine what happened, not to ascribe guilt, attribute blame or apportion liability and, by ascertaining the circumstances of a death, a coroner can identify opportunities to help reduce the likelihood of similar occurrences in

future.

UNCONTENTIOUS MATTERS

At the completion of the police investigation, and prior to the commencement of the inquest, it was apparent that a number of the facts about Glenn’s death are known and were uncontentious. These include Glenn’s identity, the medical cause of his death and aspects of

the circumstances, including the place and date of his death.

Given this, I formally find that the deceased was Glenn Albert Sanders, born on 25 November 1965, late of Derrinallum; that he died on 12 April 2014 at 1370 Hamilton Highway,

Derrinallum; and the medical cause of his death is injuries sustained in an explosion.

Introduction

The coronial brief prepared by coroner’s investigator Detective Sergeant Sol Solomon is

comprehensive.

. All interested parties fully cooperated with my investigation. Serving members of Victoria

Police, medical professionals and community members, comprised the 20 witnesses who gave oral evidence throughout the 5 day inquest. Without exception, all witnesses provided frank and forthright evidence. Where appropriate, individual and systemic shortcomings were

acknowledged. Certainly, lessons have been learnt.

I make particular reference to South West Healthcare (‘SWH’) who publicly acknowledged service shortcomings in respect to Glenn’s management whilst a client at Camperdown Mental Health Service (‘CMHS’). It is important to note, however, that despite the identified

shortcomings, CMHS has a proud history of serving its community and with lessons learnt,

3 Section 72(1), 72(2) & 67(3) of the Act

will continue to do so. Comprehensive systemic improvements instigated since Glenn’s death, graphically illustrate the determination of SWH to review and continually improve service delivery.

14. I do not purport to summarise all the material/evidence in this finding, but will refer to it only in such detail as is warranted by forensic significance and where otherwise appropriate. The absence of reference to a particular aspect of the evidence, either obtained through a witness or tendered in evidence, as well as submissions and replies, does not infer that it has not been

considered.

15. I take this opportunity to thank Counsel Assisting and the legal representatives of all interested parties and note that the submissions and replies have greatly assisted my role. I also particularly thank Detective Sergeant Solomon and Ms Jessica Wilby, Principal In-House

Solicitor, for their unstinting support throughout my investigation.

THE FOCUS OF THE INVESTIGATION

16. The issues to be considered in the inquest were set out at the commencement of the

proceeding and included:

a. What was the community’s knowledge of Glenn’s behaviour, his use of explosives

and what did they report to police?

b. What interactions did Glenn have with Police?

c. What occurred in relation to his licence to use and access to explosives in terms of

both Worksafe and police?

d. What information was shared between Police, Worksafe and the Camperdown Community Mental Health Service (CMHS)?

e. What treatment did Glenn receive at the CMHS? and

f. The details of the siege including the negotiation.

SUMMARY OF CIRCUMSTANCES

17. Glenn worked from his teen years as a mechanic for local garages and later for himself doing both mechanical and explosives work. He was described by various locals as having highly

developed mechanical skills. His friend, Kevin Simpson explained:

22,

“He was very clever, very mechanically minded. Engineering, fault finding was his forte. He could fix anything mechanical. He could make fire out of a bucket of water,

just a very clever guy.”

Glenn had previously been married to Susanne Sanders from 1998 to 2008. Susanne provided a statement saying that Glenn used marijuana and from around 2007, was also using speed.

She said that his personality around that time became paranoid and he was 'on edge! which she attributed to the drugs. Andrew Breen, a long term friend of Glenn's also stated that Glenn

was using drugs from around the time his first marriage ended.

. Glenn's second wife, Shirley Savage, died from cancer in 2012. It appears that either during

Shirley's treatment for cancer or following her death, Glenn's paranoia increased and he began

developing conspiracy theories. According to Kevin Simpson:

“The paranoia kicked in to the point where he believed that everything around him was for a reason. The conspiracy theories were crazy, he had a conspiracy theory for everything. Common theme was that he believed he was being watched. He said the

‘bundies’ was watching him. I have no idea who is talking about.”

Andrew Breen noted from the time of Shirley's death, Glenn commenced to suffer mental

health issues, which appeared linked to increasing illicit drug and alcohol use:

“He would smoke a white crystal drug through a pipe and drink a bottle of wild turkey everyday...Glenn would suffer from paranoia. He always thought people were out to

get him and his property.”

Following Shirley’s death, local residents became concerned about Glenn's increasingly

strange behaviour. For example, Gary Poole noted about a year after Shirley’s death:

“started telling me about her estate and the conspiracies and the people trying to cheat him out of Shirley's estate. He'd talk about people tracking him through his computer

and mobile phone. There's a photo in his place of him lying in a coffin.”

By 2013, local police were accustomed to hearing Glenn's tirades on subjects from being monitored by ASIO and CIA from the satellite equipment on nearby Mt Elephant, to conspiracy theories about his late wife's estate and the fact she was trading on the stock exchange 12 months after her death, to the industrial gas supplier BOS being used to spy on him after he received two phone calls about his account. He also believed his mobile phone and computer had been interfered with and he set up CCTV cameras on his property to

monitor people coming and going.

Contact with Mental Health Services

Glenn’s brother Andrew recalled Glenn saw a psychiatrist in Geelong in his late teens and again in his mid-twenties. The initial consultation was the result of Glenn’s inability to

control his emotions, which manifested in uncontrollable crying. Andrew explained:

“that was first time I probably picked -up that he was — again was always a little eccentric, a little different but that was the first time I thought, oh, hang on, there is a

bit of a problem here.”

Though unaware of a particular diagnosis, Andrew thought Glenn saw the psychiatrist about low self-esteem issues and that the psychiatrist recommended he grow a beard. He did not

recall any in-patient admissions, but thinks Glenn may have taken medication at one stage.

Local police first contacted the CMHS regarding Glenn's unusual behaviour on 25 January

2013. The CMHS revealed no prior contact with Glenn. In early March 2013, Leading Senior Constable Bruce McNaughton (then of Lismore Police Station) was concerned that Glenn's behaviour had deteriorated and required professional help. Officer McNaughton had known Glenn since 2004 and together with Leading Senior Constable Paul Avery, had regular interactions with him from 2012. Officer McNaughton did not believe that Glenn met the definition under section 10 of the Mental Health Act 1986 (which applied at the time) to apprehend Glenn because of a mental illness because he was at risk of harming himself or others. However, he contacted CMHS in relation to his concerns about Glenn. After considerable coaxing and conversation, Officer McNaughton convinced Glenn to attend

CMHS of his own volition.

Glenn officially became a client of the CMHS on 15 March 2013. His case management was conducted by Stephen Humphreys Registered Psychiatric Nurse (RPN), as his Key Worker, and Allan Woodward, psychologist, as his Clinical Therapist.

His first psychiatric review was conducted by Dr Iby Neerakal, Consultant Psychiatrist at the CMHS on 16 April 2013, Dr Neerakal diagnosed Glenn with Delusional Disorder, Needle Phobia and Polysubstance Abuse. The management plan included Risperidone 2mb nocte, to abstain from cannabis and speed and to commence case management. It transpired Glenn consulted Dr Neerakal on two further occasions on 6 June 2013 and 3 September 2013. At the June 2013 appointment Dr Neerakal noted:

“not keen for medication”, “risk was low-mod at this time” and was for “close follow

up and may need involuntary [treatment] if risks [increased].”

At the September 2013 appointment, Dr Neerakal noted:

“does not believe he has a mental illness” and is “not willing to accept treatment.”

Glenn “considering seeking a second opinion.”

27. Glenn’s former GP referred him to a private consultant psychiatrist Dr Ridley. Dr Ridley saw

har

Glenn on one occasion. He recommended that Glenn continue to seek treatment in the public sector. Dr Ridley had vast prior experience working in the public sector, and was well versed in the involuntary treatment criteria in the Mental Health Act. He diagnosed that Glenn was suffering from Schizophrenia, with delusional beliefs regarding persecution from police, together with probable hallucinatory experiences regarding the gun fire he claimed to hear, as well as being thought-disordered. Dr Ridley’s letter to Glenn’s referring GP did not include

mention of a diagnosis of Schizophrenia.

Due to Dr Neerakal’s unavailability to give evidence at inquest, Allan Woodward detailed Glenn’s clinical course at the CMHS. He explained he was able to engage and build rapport with Glenn. However, by October 2013, when Mr Woodward was preparing an Individual

Service Plan (‘ISP’) for his successor, he noted:

“unwilling to engage.... He’d been unwilling to engage before that. He came — to those meetings that he did come to, he came with his mother. He talked about his concerns. He cancelled one appointment. He wanted to go off and get a second opinion with a private psychiatrist. It was difficult to engage him, yet the instruction

from Dr [Neerakal] was to continue to make attempts to engage him.”

Mr Woodward stated he telephoned Glenn and attempted to make appointments. However, Glenn had stopped taking the prescribed medication Risperidone after 2 days and that no

further medication was trialled.

On 9 August 2013, Leading Senior Constable Simpson contacted CMHS, expressing concerns about Glenn’s behavior surrounding his past mental state and recent reports of explosions at the property. Officer Simpson advised CMHS that police would request Worksafe to suspend Glenn’s explosives licence. Officer Simpson offer to attend Glenn’s home with CMHS staff was not accepted. CMHS advised Officer Simpson that Glenn probably wouldn’t be hospitalized, but undertook to discuss his case at the next CMHS

multidisciplinary team meeting.

. Worksafe wrote to CMHS on 29 August 2013, requesting assistance on making a decision

about Glenn’s explosives licence. Mr Woodward and Dr Neerakal responded to Worksafe on

9 September 2013 detailing Glenn’s delusions, diagnosis, treatment and lack of insight.

33;

On 8 October 2013, Mr Woodward’s role as Glenn’s clinical therapist was transferred to Brian Kelly. Mr Kelly was a Registered Nurse with no psychiatric qualifications, or previous experience working in psychiatric care. Further, he was a trainee clinician who had never

previously performed the role of clinical therapist.

Mr Woodward acknowledged the complexity of Glenn’s case. At the time of handover to Mr Kelly, Glenn was not taking medication, and had essentially disengaged. Yet the severity of his mental illness would require long term treatment and engagement with mental health services. He further acknowledged the magnitude of the task confronting Mr Kelly - a trainee clinician with no psychiatric qualifications or experience. Nonetheless consultant psychiatrists had developed Glenn’s case management plan, which required fortnightly

contact and sustained and continuing efforts to engage Glenn.

It transpired that Mr Kelly’s first engagement in Glenn’s case management was 11 November 2013, in which he returned Officer Simpson’s call of 29 October 2013. LSC Simpson

expressed concerns about Glenn's behaviour having visited him at home the day before.

Officer Simpson expressed concerns about Glenn’s mental state, and offered to transport Glenn to another town to see a different psychiatrist (Glenn having expressed not wanting to engage with the clinicians at Camperdown). Mr Kelly subsequently spoke to Dr Neerakal about this matter, who was unable to agree with the proposed course. Dr Neerakal said that Glenn had already been seen by Dr Ridley and himself in the past and if his behaviour worsens he may need to be made an involuntary patient. Mr Kelly advised Officer Simpson accordingly, which prompted an offer to transport Glenn to CMHS to see Dr Neerakel.

However, Mr Kelly advised he would write a letter encouraging him to make an appointment.

On 19 November 2013, a risk assessment was performed by CMHS Team Leader Julia

Winstanley based solely on a review of Glenn’s file. She concluded that Glenn was:

““med” (or medium) risk of harm to others as “previously had access to explosives and firearms — no longer believed to have access. His persecutory delusional beliefs about others. He’s made threats to others, but not acted on those. Can be verbally

confrontational.”

At the multidisciplinary team meeting on 12 December 2013, it was noted that Glenn did not

want to be involved with CMHS and that Dr 'Iby' endorsed closure. It was noted: “BK to close this episode of care and to advise Police to re-refer if any concerns.”

Throughout his case management, Mr Kelly did not meet Glenn. He wrote several letters to

Glenn, and in early December 2013 attempted to phone him. His sole contact comprised

39,

eary

44,

receiving a phone call on 5 December 2013, in which Glenn stated he wanted no further contact from CMHS, and that he would continue to consult his GP, Dr Fitzpatrick. Mr Kelly

advised Dr Neerakel accordingly.

On 17 December 2013, Mr Kelly wrote to Glenn informing him of the decision to close his case management, recommending continued involvement with his GP, referral to a private psychologist and inviting him to contact the service if he had any concerns. The last time

Glenn had been seen by the CMHS was 3 September 2013.

In evidence, Mr Kelly frankly acknowledged that due to his minimal contact with Glenn, he was not in a position to form a clinical judgement, one way or the other, whether Glenn posed a risk to himself or others at the case closure meeting in December 2013. He described his ability to contribute to the team decision to close Glenn’s case as inadequate. However,

he stated he had faith in the ability of the team to make the decision.

. 1 do not propose to criticise the decision to close Glenn’s case, However, the decision was

underpinned by the knowledge that without treatment of his serious mental illness, Glenn’s mental state would likely deteriorate. It was an essential component of the case closure plan that Glenn’s GP, Dr Fitzpatrick and members of Victoria Police were advised of case closure and further, would continue to engage and monitor Glenn. Regrettably, neither Dr Fitzpatrick

nor members of Victoria Police were so advised.

Officer Simpson who had offered Glenn extraordinary support had no further contact with Glenn after his telephone calls to Mr Kelly in November 2013. He understood CMHS would

continue involvement in Glenn’s management.

Dr Fitzpatrick was particularly aggrieved that he was not informed of CMHS case closure.

He spoke in glowing terms of the excellent relationship he had always enjoyed with CMHS.

However, he was adamant he should have been informed of case closure and equally adamant, if informed would have firmly rejected any proposal he treat, manage and/or monitor Glenn’s mental state, He firmly stated his lack the professional expertise to perform

such a role, in consideration of the seriousness of Glenn’s mental illness.

I consider Dr Fitzpatrick a particularly impressive witness and a most dedicated General Practitioner. He last saw Glenn on 25 February 2014. Glenn’s mood was very elevated, he was unwell, indeed the worst he had seen Glenn. He did not call CMHS because he quite reasonably believed they continued to manage Glenn. In the circumstances in which CMHS had not informed Dr Fitzpatrick of case closure, in my view, there is no reasonable basis to criticise him for not calling CMHS. Further, I have no doubt had he known CMHS were not

involved, he would have unhesitatingly called them.

Use of Explosives and Suspension of Licence

It was widely known within the community that Glenn detonated explosives on the farm at various times during the day or night. Glenn had a 'License to Use Blasting Explosives' and a ‘Permit for Unsupervised Access to HCDG (High Consequence Dangerous Goods)’ under the Dangerous Goods Act. Glenn had begun working with explosives at around 18 years of age and obtained a licence later and earned money from blowing bores or cleaning bores in farming country or blowing holes in the water table to redirect water to bores for farmers and local people. Glenn made home-made explosives — a friend had seen him mix liquids and

gases and place them in cylinders around the farm.

On 7 August 2013, having received an anonymous call about explosions in the Derrinallum area, Officer Simpson suspected Glenn was responsible. Coupled with his concerns for Glenn’s mental state, Officer Simpson contacted Allison Dennis at Worksafe in respect to what could be done to revoke Glenn’s licence to use explosives, and have them removed

from his possession.

Worksafe in Melbourne learnt that police had earlier suspended Glenn's firearms licence and removed his firearms due to concerns about his mental health. Worksafe had made requests of CMHS for information as to Glenn’s mental state, and this, in conjunction with a complaint of explosions at the farm the previous evening, led to the Worksafe decision to suspend Glenn’s licence and requiring him to surrender all explosives in his possession to an

authorised officer.

On 16 September 2013, Worksafe inspectors Allison Dennis and Paul McCoy of Warmambool attended Glenn’s property in the company of Senior Sergeant Darren Savickas, manager of the Corangamite Police Cluster, as well as three other police officers. The police officers were there to accompany the Worksafe inspectors rather than executing any separate purpose. Upon arrival, Ms Dennis identified herself to Glenn and served a copy of the licence and permit suspensions on Glenn. Ms Dennis gave evidence that upon attending Glenn's property she had not received any information about the number or types of explosives or materials that Glenn held. Ms Dennis gave evidence that the way of finding how many explosives a person had purchased was by inspecting the sales books of explosives sellers.

However, this was not something she would normally do. In any event, a licence holder is not obliged to record how many explosives they use, so it could not be ascertained how many

explosives a licence holder possessed at a given time. Further, prior to attending the property,

rare

DEP

Ms Dennis gave evidence that she had no information about the layout of the property or

what structures were on the property.

Glenn showed Ms Dennis where he stored explosives, in a shipping container adjacent to the cattle yards at the rear of his main workshop shed and house. Ms Dennis also inspected other structures on the property including the other shipping containers, a bus shed, workshop

shed, 'Shirley's' shed, the old dairy, an open shed and a Bedford truck.

After the explosions on 12 April 2014, police discovered an underground bunker and a buried shipping container on Glenn's property. Worksafe inspectors were not aware of these underground spaces and did not inspect them on 16 September 2013. There is no evidence available to me to suggest the underground spaces contained explosive materials during the

time of the Worksafe inspection.

. While it appears many locals who provided statements to the Coroner's Investigator

were aware of one or both of the underground spaces, it appears that none of the police witnesses who gave evidence were aware of their existence until after Glenn's death. When asked if she would look for places where a person might secrete explosives, Ms Dennis said

she would look for indicators that explosives had been used or stored, explaining she would:

“look for the equipment or the ancillary items that would be used when you were preparing explosives. I'd look for a cleared area that was free of anything that might be an initiator, So obviously I don't want to see electrical, or something like that. I would look for storage containers. I'd look for packaging. I'd look for old boxes of I'd look for some of the equipment that you might use when you're preparing or digging

to lay your charges.”

Worksafe inspectors removed explosive materials from the property on 16 September 2013, including amongst other things; safety fuse, detonation cord, Cordtex, detonators, nitrophil, sticks of ‘Magnum’ sentinel explosive and ammonium nitrate. At inquest, Ms Dennis explained she was not aware of any follow up procedure in relation to checking whether a person is using or accessing explosives after their licence has been suspended. Of note, a person would not be able to purchase explosives without a licence. Statements from Victorian explosives suppliers Ashley Richens and Thomas Clonan revealed that no explosives had been sold to Glenn after the suspension of his licence and permit. It appears

that at that time, there were only two suppliers of explosives in Victoria.

Ms Allison acknowledged, in hindsight, in consideration of the scale of the search, and in particular the vast array of heavy equipment within the structures on the farm, the dog squad

would have been of assistance.

Community Knowledge of IED

54. My investigation has revealed that at least 12 months prior to his death, Glenn began telling

or showing local residents of Derrinallum that he was wearing an improvised explosive

device (IED) under his clothes in a black bra. The bra was variously described as containing

gelignite and having a safety switch, having wires and a battery and a chin switch so he could

detonate it if his arms were held, or having switch detonators on the shoulders so he could

activate it with his head. Accordingly, there were a number of Derrinallum residents who saw

or knew that Glenn was wearing a bra containing an IED from as early as 12 months prior to

his death, who did not pass the information onto police or any local authorities. After Glenn’s

death, a number of local residents advised my coronial investigator, Detective Sergeant Sol

Solomon, of their respective experiences:

Around April 2013, a resident saw Glenn wearing a bra filled with explosives; that Glenn wouldn't leave the house without wearing it; that Glenn would often go to

town wearing the 'vest';

In May 2013, a resident was told by Glenn he was wearing a bra that was packed

with explosives but declined Glenn’s offer to sight it;

In August 2013, a resident saw the bra worn by Glenn, containing a battery and 8

sticks of explosives in each cup and a chin switch;

In September 2013, a resident saw the bra. That Glenn stated he wore it in case the

police or psych try to take him away;

In either September or October 2013, Glenn asked a resident to feel the bra straps, explaining the bra was strapped with gelignite and was worn to avoid being detained

in a psychiatric facility;

In early October 2013, a resident saw the bra with 10 sticks of gelignite but wasn't

sure if it was actually explosives;

In December 2013, a resident saw Glenn wearing the bra containing an IED and

Glenn told him that it was set to detonate;

Around Christmas time 2013, Glenn informed a local businessman the farm was booby trapped. Further, that the entire farm would blow up and he would take as many people as he could. Glenn stated it didn't matter his explosives licence was removed because he knew how to manufacture his own explosives. The businessman further stated in the 18 months prior to Glenn's death, Glenn had told him that he

was wearing an explosive vest on 3 different occasions, however he wasn't 100 percent sure Glenn was carrying explosives. He explained it was common

knowledge that he wore explosives and that other residents had seen them;

— Approximately February 2014, Glenn showed a resident the bra with the explosives in the Derrinallum township. He also stated it was common knowledge in the town

that Glenn was wearing explosives;

— A few weeks prior to Glenn's death, Glenn visited the family home of residents

and revealed a bra filled with explosives;

— In late March 2014, Glenn told a resident whom he had previously discussed the

TED:

“he had "finally finished it. It's taken two months but when I go, everything

goes.

55. Residents offered my investigation various reasons for failing to inform police of their

knowledge or suspicion that Glenn was wearing explosives, including: — didn't really know for sure what Glenn meant so he didn't say anything to anybody; — thought Glenn was wary of police and Glenn could turn on her:

— mixture of loyalty to Glenn and because he wasn't sure what Glenn would do if

confronted by police, stating:

“It was very difficult because I didn't want to betray our trust and friendship, but I asked my father for advice and explained to dad what - what was going on. He was shocked of course. I weakened a few times - weakened is probably not a good word - and tried ringing the local police station. It’s a one-man station, small country town, Scott’s not there all the time, sort of thing, got the answering machine, I thought, “No, I can’t do it because if — if I called Scott and said, “Scott” — apparently he already knew — “Scott, you need to get up there and do something about that” — you’re going to kill Scott too, so ‘cause they’re going to come in and Glenn’s going to set it off and take other people out with him as well, sort of thing, so I really didn’t know what to do... You’re trapped between betraying your friend and,

and maybe killing him and somebody else, or try and keep helping him.”

Police knowledge of IED

On occasions, suspicion or belief that Glenn wearing an IED was communicated to police.

On 14 May 2013, a resident who sought anonymity, informed police members that Glenn stated:

“are going to get me but I will take them all with me. Cops don't frighten me but

there's nothing wrong with me and I'm not going to the nut house.”?

The caller’s complaints were conveyed to a senior officer, Leading Senior Constable

Clissold. Officer Clissold noted an anonymous male, who had not sighted explosives:

“was told by Glenn Sanders that he had strapped explosives to himself and was going

to blow himself up.”

Officer Clissold made a series of enquiries of fellow officers, and requested Officer Avery to telephone Glenn to ascertain his state of mind. Officer Avery knew Glenn and having spoken to him, advised Officer Clissold that Glenn was fine and appeared his normal self. Officer Clissold formed the view the concerns were unwarranted. However, Senior Constable Rogers completed a personal warning flag on the LEAP system that included information about

Glenn’s paranoia, his drug use and a note:

“alleged (not confirmed- 3rd party) evidence at hand seems to be over stated that Sanders may blow himself up. Members should approach with caution with backup,

for future information of members.” In around July 2013, Officer Rogers was out socially when a resident told her:

“be mindful when attending [Sanders] address ... he was ““Loaded" and had explosive

[sic] which he would carry with him while at his house.’ She asked the resident what he meant by loaded but was told:

“he didn't want to get involved but wanted to make sure I am aware when attending

his address."

Officer Rogers considered this information confirmed what she had submitted in the personal

warning flag in May 2013. Upon returning to work she:

“reiterated verbally to members in our police service area that Sanders has CCTV cameras and it was alleged that he was carrying explosives while at his home

address.”

Officer Rogers explained that no-one was prepared to elevate concerns beyond rumour:

“Tt was all rumours and um because no one was willing to - hadn't physically seen it, it was all just - yeah ...as for the explosives, it was all just - yeah, no physical evidence given and wouldn't provide any information. And he hadn't physically seen

it, it was all just what he'd been told.” Officer Simpson could recall Officer Rogers’ conveying the resident’s complaint that:

“Glenn was loaded and had explosives, which he would carry around his house and

that she should be careful.”

Officer Simpson shared Officer Rogers’ assessment that the concerns were rumour, rather

than hard information.

About 6-8 months before Glenn's death, Glenn revealed to a resident a black bra which appeared to contain half sticks of gelignite taped in, a battery, 3 switches and wiring connecting the components. Though unsure if it was bravado or genuine, a week later the resident informed Officer Simpson, explaining he could not guarantee authenticity. Officer Simpson recalled the conversation, which did not elevate concerns beyond rumour. He explained in order to consider the information credible, he would require someone to put

their name to a statement containing the information.

On 28 October 2013, acting on rumours circulating about Glenn having or wearing explosives, Officers Simpson and Avery attended the farm. They spoke to Glenn for several hours, listening to Glenn espouse his conspiracy theories. They urged Glenn to engage with CMHS or his paranoia would destroy his life. Officer Avery directly asked Glenn on two occasions, if the rumours about him wearing explosives were true. Glenn again did not

answer directly but said the town had nothing to fear. He just wanted to be left alone.

Officer Avery thought Glenn was wearing his flannelette shirt in an unusual fashion, and appeared hunched over. However, he considered as Glenn's firearms and explosives licences had been suspended and explosives confiscated, the shirt might be full of tissues as an apparatus to negotiate with police if anyone tried to take him to a ‘padded cell’. For his part, Officer Simpson held no concern that day that Glenn was wearing any explosives. He felt that Glenn probably wanted people to think he had ‘something like it.’ In any event, both officers explained they had no search powers to enable them to ask Glenn to remove his shirt

on that day.

Following the visit, Officer Simpson submitted an Information Report to Warrnambool

Divisional Information Unit containing information about Glenn's paranoid beliefs and

information about his mechanical and engineering skills. As detailed above, he also contacted

the CMHS.

66. Kevin Simpson, a long-term friend, was aware of Glenn’s deteriorating mental state. Upon hearing a report that Glenn was wearing a bra containing explosives, when visiting his mother in hospital, he was understandably concerned. On 31 March 2014 he informed Senior

Constable Mark Howard at Ballarat Police Station.

67. Officer Howard then contacted Glenn's brother Andrew who confirmed sighting the IED under Glenn's shirt at the hospital on 28 March 2014. He believed the explosives were genuine. Officer Howard contacted another resident who reported previously seeing the

device.

68. Officer Howard contacted the Arson and Explosives Squad of Victoria Police in Melbourne

and spoke to Detective Leading Senior Constable Andrew Beans.

69. Officer Howard filed an information report, which he emailed to a link provided by Detective Beans. The information report contained the information that Officer Howard had obtained from the 3 witnesses. My investigation has revealed that due to internal police processes of vetting and validation, Detective Beans did not access the report until the afternoon of 4

April 2014.

Arson and Explosives Squad response to Officer Howard’s Information Report

70. From that time, and appraised of the information contained in the information report,

Detective Beans said:

“When I became fully armed with that information, obviously that, that starts to really build your reasonable suspicion and we're moving into reasonable - towards reasonable grounds. Information always needs to be corroborated. From a personal (indistinct) point of view, I commenced an investigation codenamed "Operation Geologizes" and this information was communicated to my supervising team and um,

the investigation was underway. “

71, On 4 April 2014, Detective Beans commenced an affidavit for a search warrant; progressed

the investigation and compiled information regarding Glenn, explaining:

“We've started to review the information at hand which is contained in all the information reports that related to possible history of mental illness. Um, recent searches of the property, the removal of explosives by WorkSafe and contact with Mr Sanders, recent communication between local members and Mr Sanders um, and we

would start looking at - certainly risk assessments and I commenced an affidavit for a

search warrant.”

72. When asked generally about the level of urgency and what action was taken in response to

the information held on 4 April 2014, Detective Beans responded:

“We would heavily rely on - on entries that are made on our databases to form our belief or suspicion, rightly or wrongly. Um, we rely on the fact that the premises has been previously searched. Ah, he's been cooperative with members previously.

WorkSafe, that we could see, had been there and removed all explosives. The information over time ah was inconclusive as to where - when he first wore an alleged bra and are we dealing now with a person that possibly had access to explosives a while ago, but has since lost his licence and lost his explosives, and are we dealing with someone that may be wearing something that is there to look like one, to scare people. Bearing in mind, we were also dealing with, what we could see, was someone that was suffering from a mental illness as well. So we were drawing these conclusions at that stage and - and I can only suggest that their - the squad were

prioritising a response based on those facts.”

73. Detective Beans disputed any suggestion of an apparent lack of urgency to investigate such

serious concerns:

“T believed that it was treated extremely seriously. Um, and prioritise as a - as an operation. Um, and we had a planned response. Um, time is the essence ah - the reaction from the squad ah for many reasons, ah I can't provide exact reasons today as to why we didn't move on it immediately. Only that ah we were dealing with the

information that we had at hand, ah our capabilities at that point.”

74. In hindsight, Detective Beans acknowledged local detectives could have been tasked to

obtain statements from the complainants, rather than await the availability of Arson Squad

members.

On 9 April 2014, Officer Howard returned to work, albeit during his recreational leave. He received a call from Mr Poole asking what was happening with respect to Glenn. Mr Poole detailed what had occurred to him when visiting the farm that day — that he went with Glenn into his garage and down into his mechanics pit to look at a car. Glenn then allegedly rolled a 44 gallon drum over the entrance, trapping Mr Poole inside, and began to release vapor from a glass cylinder into the pit. Glenn was highly paranoid and threatened to take a local child in order to get the answers he said he wanted from the local people. Mr Poole managed to

escape the pit. Mr Poole also reported that Glenn had a bra that contained explosives that he

wore nearly everywhere and that it had three switches which he can detonate using his head

if his hands are being held.

Officer Howard immediately contacted the Arson and Explosives Squad and spoke to Detective Gorgorossis. He then forwarded the information from the information report dated 31 March 2014 to Detective Gorgorossis. SC Howard also contacted his Section Sergeant

and consequently, an operation in relation to Glenn commenced.

Police actions on 11 April 2014

Fhe

79:

Following the report from Mr Poole, Detectives from Warrnambool took charge of the investigation and sought special advice from the Bomb Response Unit and obtained a search warrant for Glenn's property. Due to the high risk, support was also requested from the SOG

to safely take Glenn into custody.

.On 11 April 2014 Glenn left his property early in the morning and drove to Ballarat to visit

his mother in hospital. A surveillance team was deployed to keep him under observation.

Surveillance teams observed Glenn drive to Sovereign Hill and then a service station. He

then visited his brother Andrew, then returned to St John of God Hospital.

At 2:23pm that afternoon the SOG received confirmation from Andrew that Glenn was wearing an IED on his body - SOG members were deployed to the hospital to monitor Glenn.

The SOG commander advised members to take any emergency action required if Glenn became a threat to the public and the situation became critical. At 3:56pm Glenn went to Bunnings where he purchased a timer device. He then went to Coles where he purchased

groceries and drove to Derrinallum.

At 4:50pm the SOG received information from Andrew that Glenn was an ice user, the doors to the farm were booby trapped and that he has home-made IEDs and other explosives on the farm. At approximately 6pm Glenn returned to the farm and at 6:15pm SOG personnel determined that the best option was to put a safe perimeter around the farm, that Glenn be asked to show himself, remove the improvised explosive device and peacefully surrender to

police.

According to forensic examinations by police, it is not possible to determine how the explosive train was initiated but it is probable that charges were initiated by a timer type device from inside the main house which was probably destroyed in the blast. It appears the significantly smaller explosion inyolving Glenn occurred independently of the other explosions. It could have been operated only directly, either accidentally or inadvertently, or

by deliberate initiation by Glenn, through depression of one of the shoulder switches.

Negotiation

Negotiations were initially undertaken by Officer Sykes, from approximately 6:50pm (before he exited his house) until shortly after 10:00pm, and subsequently by Sergeant Chandler, until the explosions occurred at around 1:20am on 12 April 2014. Glenn was co-operative with negotiators, removing his shirt to reveal a device strapped to his chest. Both negotiators gave evidence that they continued to relay to Glenn the surrender plan throughout the

evening.

Officer Sykes began negotiations through an SOG operative from inside the Bearcat vehicle and over the PA. However, he could not hear what Glenn was saying because of the ballistic value of the vehicle. Accordingly, he moved to the rear of the Bearcat and continued to

negotiate directly with Glenn.

Glenn told SC Sykes that he'd been wearing the vest for a long time as he believed people

who he described as 'scammers' had been entering his property. He consistently stated:

“I’m not going to prison, I don't want to go to prison ...Grant, I'm not coming, there

is no way I'm going to take my vest off.”

Officer Sykes stated Glenn had obvious mental health issues and when he asked him which Doctor or case worker he saw, Glenn replied 'I don't know any names.' The conversation went around in circles, with the surrender plan regularly explained. However Glenn repeated

throughout the evening:

“Sorry Grant, I'm not going to do it, the only way the vest is coming off is when it blows up.” Glenn apologised profusely about the situation, explaining “I don't want to hurt police, police are just doing your job ...I don't want any police to be hurt when

the vest goes off.”

Sergeant Chandler took over negotiations from Officer Sykes, saying he got enough information to initiate a role change. Glenn continued to espouse his paranoid theories to Sergeant Chandler. When Sergeant Chandler tried to convince him that the townspeople were not spreading stories about him, he would continue to ramble on about why his theories were true. At no time did Sergeant Chandler consider Glenn was considering detonation. He was not angry - his demeanour never changed. At the time of the first explosion, Sergeant Chandler had fortuitously moved slightly behind the Bearcat vehicle while Glenn was

talking. There was no alteration in Glenn’s conversation or demeanour.

Prior to police attending the farm, Andrew Sanders informed police that Glenn had a ‘trap

set’ — he offered to assist police with the negotiations. Operator 6 said he was advised by

~

89,

Operators 139 and 140 that they had spoken to Andrew. He said that he believed it was highly likely the house was booby trapped although he was aware local police had attended in previous months and attended inside the house. Operator 6 also said he was told that Andrew had said the place was wired up with explosives and would be flattened. Operator 6

said:

“SOG personnel had been briefed regarding the potential harm that Sanders could cause them, and the measures they needed to protect themselves from the assumed explosive threat, which included remaining an extended distance up to 300 meters from the property and using protective cover such as large trees or dips in the

ground,”

. Officer Sykes acknowledged he was told the property was likely booby trapped. SC Sykes

asked Glenn if there were any explosives around the property and Glenn did not divulge any information. Sergeant Chandler was unaware of information that the property may be booby-

trapped. Operator 94 was aware that:

“... he had potentially booby trapped — booby trapped the properties, ah being the front doors of the properties. Um, and that he was wearing that IED ... and also that the letterbox was potentially booby trapped.”

He also was informed about a quantity of liquid hydrogen later in the night, but said it was

raised and later discounted.

Sergeant Chandler was unaware of Andrew’s offer to assist negotiations, but explained there

were many reasons why a third party would not be involved in negotiations.

Officer Sykes recalled Glenn asking him what the time was at least once during his negotiation. Operator 94 who was within earshot of the negotiations, said that he heard Glenn ask what the time was a couple of times, he said that it was within a couple of hours of the negotiations commencing. In hindsight, Operator 94 believed that when Police first arrived, Glenn went back inside his house and initiated a timer device, before coming outside, which ultimately went off at around 1:20am. He said that there was nothing else that Glenn did that

night that seemed causative of the explosions being set off.

Glenn’s friend Mr Breen stated that Glenn had mentioned that he had bombs hidden on the farm, some which could go off in 12 months time. Glenn reportedly told Mr Breen that he

could use the alarm buzzer from any mobile phone as a timer and trigger for a detonator,

Analysis and conclusions

What was the community’s knowledge of Glenn’s behaviour, his use of explosives and what

did they report to the police?

91. A considerable number of statements from members of the Derrinallum and surrounding community suggest that there was widespread community suspicion and knowledge that Glenn was wearing an IED on his person while at home and when out in the community for up to a year prior to his death. For those who didn’t alert police about the IED, their reasoning included that they were scared to do so for their own safety, police safety or Glenn’s safety. Others had similar concerns as well as being loyal to Glenn and not wanting

to betray him to police.

What interactions did Glenn have with police?

92. While there were reports to local police about Glenn wearing an IED, police were unable to obtain a witness statement to the effect that someone had seen the device. Accordingly, local police collected and reported information through information reports which were provided to the Warrnambool Divisional Information Unit. Information was also shared between local police stations regarding Glenn’s strange behaviour, paranoid beliefs and rumours regarding him wearing explosives. Despite making further enquiries of Glenn, police were not able to

substantiate rumours about Glenn wearing explosives.

What occurred in relation to his licence to use and access explosives in terms of both

Worksafe and police?

93. As a result of Glenn’s strange behaviour and paranoid beliefs, police acted to remove his firearms licence and notified Worksafe about their concerns. Worksafe collected information regarding Glenn and made a decision to revoke his licence and permit to use and possess explosives. An inspection of his property resulted in the seizure of Glenn’s explosives and explosive materials on 16 September 2013. There were underground spaces including a bunker and a shipping container on the property that Worksafe and police were not aware of and they were not searched. However, there is no evidence that Glenn had secreted explosive materials in those places during the inspection in September 2013. There is also no evidence to suggest Glenn purchased any further explosives after his licence and permit were revoked.

Local people reported that Glenn could make homemade explosives. Ultimately, there is

insufficient evidence to suggest how Glenn obtained the explosive material he used on 12

April 2014 to blow up the buildings on his property.

What information was shared between police, Worksafe and the Camperdown Community

Mental Health Service (CMHS)?

94. Local police contacted the CMHS regarding their concerns about Glenn’s behaviour and his

mental health on multiple occasions. Whether as a result of drug.use including speed, ice and cannabis or otherwise for internal reasons, Glenn was suffering from either Delusional Disorder or Schizophrenia. In either case, it was marked by persistent paranoia and persecutory themes, Apart from some early engagement with psychologist, Allan Woodward, Glenn was unwilling to engage with the CMHS. He attended with the psychiatrist Dr Neerakal at CMHS on 3 occasions and sought a second opinion from a private psychiatrist, Dr Ridley on one occasion. Case management was unsuccessful after September 2013. The CMHS persisted in trying to engage Glenn by making phone calls and attempting to arrange

appointments at the Service.

What treatment did Glenn receive at the CMHS?

OF.

Glenn resisted CMHS strategies to engage him. Police offers to transport Glenn to CMHS or to another service were not accepted. A decision was made to close Glenn’s case management and registration with the service in December 2013. Glenn’s GP was not contacted to advise him that Glenn was being exited from the service. Local police who had been in contact with the CMHS regarding their concerns about Glenn’s behaviour, were not contacted about Glenn being exited from the service. In the circumstances of Glenn’s diagnosis, his lack of engagement with clinicians, concerns by police, polysubstance abuse and risk assessment as being a ‘medium’ risk of harm to other, it was not reasonable for the

CMHS not to contact both the GP and local police about closing the file.

Glenn’s GP, Dr Fitzpatrick, and Senior Constable Simpson held serious concerns for Glenn’s mental state. They were fortified in the belief that CMHS were involved in the management

of Glenn.

Neither Glenn’s GP nor CMHS were aware of the IED concerns.

CMHS knew Glenn suffered a serious mental illness, used illicit drugs, had no insight, was non-compliant with psychotropic medication, was difficult to engage and would require long term treatment. Dr Ridley, consultant psychiatrist, explained that without treatment, Glenn’s

mental state would deteriorate.

99. Following handover on 8 October 2013 from clinical therapist Woodward to Brian Kelly, the

management plan included a requirement for fortnightly contact. There was in fact no personal contact between Glenn and Mr Kelly. It must be noted that Brian Kelly was a trainee clinician, with no psychiatric qualifications or experience. It would always be the case that Brian Kelly would struggle to engage with Glenn, in particular, where his vastly more

experienced predecessor had failed.

The basis for case closure was largely due to Glenn’s disengagement and the apparent increased distress and agitation caused by CMHS’s efforts to engage him. The closure decision was underpinned by the belief of a consultant psychiatrist that Dr Fitzpatrick and Victoria Police, notably Senior Constable Simpson, would closely monitor Glenn and would identify and act upon any perceived deterioration in Glenn’s mental state. Further, an essential component of case closure, of particular importance to Glenn’s case, was the

necessity to advise Dr Fitzpatrick and Senior Constable Simpson.

Neither Dr Fitzpatrick, nor any member of Victoria Police was notified of CMHS case

closure.

Caroline Byrne, former head of CMHS, acknowledged that the offer of Senior Constable Simpson to convey Glenn to CMHS for psychiatric review by Dr Neerakal should have been accepted — albeit due to Dr Neerakal’s busy schedule, not for 4-6 weeks. Nevertheless an appointment should have been made with Dr Neerakal and Officer Simpsons offer to

transport Glenn accepted.

Ms Byrne heard the evidence of Dr Fitzpatrick. In particular that he lacked the professional expertise to manage/treat Glenn due to the severity of Glenn’s mental illness, and that he would have rejected the role CMHS had identified he would perform. Therefore had Dr Fitzpatrick been advised of CMHS case closure, his firm rejection of a continuing role in Glenn’s management would most certainly have led to a reconsideration of the case closure decision. Further, the CMHS team would be required to undertake a ‘face to face’ assessment

of Glenn’s mental state.

I consider the failure to notify Dr Fitzpatrick and Victoria Police a serious oversight.

However, it remains a matter of speculation to find that a face to face meeting would have necessarily resulted in an involuntary treatment order and/or would have averted the tragic outcome. I do find however that the failure to notify Dr Fitzpatrick and Victoria Police constituted a missed opportunity to engage and treat Glenn, notably administration of

psychotropic medications and intensive case management.

The details of the siege including the negotiation

111,

Although proximate to the ultimate action by police on 11 April 2014, the Arson and Explosives Squad were informed on 31 March 2014 about concerns that Glenn was wearing an IED. It appears that detailed information was not received by the Arson and Explosives Squad until 3 or 4 April 2014 regarding recent concerns from multiple sources that Glenn

was wearing an JED.

It cannot be said that the outcome would have changed had the Arson and Explosives Squad reacted immediately and proactively to the information it received on 3 or 4 April 2014, rather than 11 April 2014. However, given the gravity of the information in the information report, little action was taken in relation to the information prior to Arson and Explosives Squad being contacted again on 11 April 2014 regarding Glenn. This appears to result from insufficient priority being given to the information report when it was received on 3 or 4 April 2014, which contained reports from three different sources, that a man with a mental

illness was wearing an IED vest.

I consider the 31 March 2014 information report, which was received on 4 April 2014, should have attracted an immediate response. | accept the investigation was instigated on 4 April 2014, however, the allegations warranted an urgent response. Local detectives should have been properly tasked with obtaining statements from complainants. I have noted

however, in open court, that I do not consider the delay a cause of the tragic outcome.

I make no adverse comment about the manner in which Victoria Police responded to the alleged assault of Mr Poole on 10 April 2014, including the decision to surveil and

subsequently arrest Glenn at his home.

Further, in respect to the arrest plan, I do not consider anything further could have been

undertaken to avert the tragic outcome.

Glenn wore an IED and any endeavour to arrest him would have been fraught. It could not safely occur in a public place. Victoria Police could not know the nature of the explosive capacity of the IED. They only learnt the situation once he removed his shirt during

negotiation.

Officer Sykes had read the information report and received verbal intelligence prior to commencing negotiation. He knew intelligence included potential booby-trapping of the

farm. SOG operatives were equally aware. Although Sergeant Chandler read the report, I

accept his evidence that he was unaware of potential booby-trapping. He expressed surprise

SOG members would form a cordon in such circumstances.

1 make no criticism of Officer Sykes for not verbally handing over to Sergeant Chandler information which he would have assumed Sergeant Chandler would have gleaned from the intelligence report prior to handover. In any event, both negotiators had no doubt Glenn did not wish to harm any police officer, Officer Sykes informed him police members had formed a cordon on the property. He specifically asked Glenn if there were any other explosives

around the property. Glenn did not divulge any response in the affirmative.

Had Sergeant Chandler known of intelligence in respect to potential booby-trapping of the property, he would no doubt have asked Glenn the same questions asked by Officer Sykes,

and one can infer would have received the same response.

I do not consider the SOG tactics, and the intelligence upon which their decisions were made, relevant to my inquiries. My investigation relates to the circumstances of death of Glenn; specifically whether his death could have been reasonably averted, and whether the tactical

decision employed to safely arrest Glenn were reasonable and appropriate.

As indicated earlier, I am so satisfied.

IT am informed that the CCP has reviewed all aspects of Victoria Police response, which include the appropriateness of the various tactics, given the available intelligence of potential booby-trapping.

Despite the tragedy of Glenn’s death, together with serious injuries to SOG officers, Victoria Police strove to safely arrest Glenn, and avoid potential civilian casualties. They faced a

challenging task. I make no adverse finding in respect to the attempted arrest.

At that point, it was necessary for police to act on the allegations made by Mr Poole (including the actions against Mr Poole and the threats Glenn made about taking a local child) by seeking to arrest Glenn. Negotiators worked for a long period of time to try to convince Glenn to work with police and remove the IED vest he was wearing. While the detonation of the vest was a constant threat throughout the evening, there were no signs that Glenn was going to trigger the series of explosions that occurred from 1:20am on 12 April

While it cannot be stated with any certainty, it is likely that Glenn had set a timer device when police arrived at his property on 11 April 2014, which resulted in the explosions some

six hours later, based on:

a. Glenn having told one local, “I’ve finally finished everything, it’s taken 2 months,

but when I go, everything goes”; b. Glenn having told others he was capable of using timers to detonate explosives; c. That he returned briefly inside before coming out to speak to negotiators; and d. That he was not seen to trigger any device before the explosions.

Glenn died as a result of explosives he had strapped to his own body which were detonated

either:

a. inadvertently, perhaps as a result of movement caused by the house explosion which

occurred behind him moments before; or b. asa result of him deliberately detonating the device.

In either of those cases, Glenn was responsible for the explosion that caused his death.

The CMHS initiatives implemented post this tragedy

122,

127,

The initiatives implemented following comprehensive review, reflect responsible learning from Glenn’s management. The primary learning relates to enhanced information sharing, which now includes regular and fulsome liaison between Victoria Police, CMHS and GPs,

the result of which facilitates the best clinical outcome.

I accept the evidence of Dr Ridley, that the section 8 criteria for involuntary treatment under the Mental Health Act 1986 must be interpreted broadly. Common ground is that Glenn suffered a serious mental illness. He had no insight and would not consent to treatment — notably antipsychotic medication. Without medication, Glenn’s mental health would

deteriorate.

Dr Ridley explained that the section must be viewed in consideration of the risk of

deterioration in mental health or rehabilitation, without treatment.

I consider Dr Ridley’s evidence accurately reflects the interpretation of S. 8. However, Dr Neerakal was unavailable to give evidence. It is open on the evidence to find that he did consider the potential deterioration in Glenn’s mental health, in conjunction with Ms

Winstanley’s assessment that Glenn did not pose a risk to himself or others.

Indeed, the key plank of the case closure plan was to notify Glenn’s GP and local police

members, and that they perform the respective treatment monitoring role.

I have no basis to find that Dr Neerakal would not have closed Glenn’s case had he known

that Dr Fitzpatick considered the severity of Glenn’s mental illness beyond his expertise, and 27 ,

further that he was not willing or able to perform the role identified in the case closure plan.

In any event, Ms Byrne has acknowledged that in light of Dr Fitzpatrick’s evidence, the case would not have been closed without a face to face consultation and risk assessment of Glenn

— likely to be conducted at his farm.

CMHS accepts this was a serious oversight. In February 2014 Dr Fitzpatrick noted a serious deterioration in Glenn’s mental state. He was comforted in the belief that CMHS were continuing to treat Glenn and accordingly did not contact CMHS with his concerns. ] make no criticism of Dr Fitzpatrick for not contacting CMHS in circumstances where he

reasonably believed CMHS were continuing to treat and monitor Glenn.

Dr Fitzpatrick was alarmed to learn CMHS had in fact closed the case the previous year. Had he known, Dr Fitzpatrick would have been very concerned. Further, he would have contacted CMHS and clearly explained he was neither willing nor able to meet, monitor or treat Glenn,

in light of the seriousness of his mental health illness.

I consider the failure of CMHS to advise Dr Fitzpatrick and Victoria Police of case closure, was a missed opportunity to continue CMHS treatment of Glenn, including consideration of

involuntary treatment either in hospital or a community treatment order in the community.

Despite the seriousness of this error, absent speculation, I am unable to find the failure of CMHS to notify a general practitioner and Victoria Police would have averted the tragic

outcome.

I am satisfied that initiatives in respect to collaboration with all stakeholders, including

Victoria Police, will best ensure similar failings of information transfer are averted.

Reviews the Victoria Police has undertaken and conclusions

The Critical Incident Management Review Committee (CIMRC), chaired by Deputy Commissioner Cartwright, conducted a review of the incident involving Glenn with an initial examination of Victoria Police policies and practices in responding to the incident. The conclusion of the CIMRC review was that the application of organisational policy rules and procedural guidelines undertaken prior to and during the incident was consistent with

accepted organisation practice.

Aside from implementation of the recommendations of the CIMRC Review, there have been

no other changes to policies, procedures and training arising from Glenn’s death.

FINDINGS

Having considered all the evidence, in the circumstances described above:

135. I find that Glenn Albert Sanders, born on 25 November 1965, died on 12 April 2014 at

Derrinallum from injuries sustained in an explosion.

136. I make no adverse finding against any of the police officers involved in the incident.

137. Texpress my condolences to Glenn’s family.

138. TIalso express my condolences to officers injured in this incident.

139. Pursuant to section 73(1) of the Coroners Act 2008, I order this finding be published on the internet.

140. Idirect that a copy of this finding be provided to the following: a. Glenn’s family; b. VGSO on behalf of the Chief Commissioner of Police; c. Solicitors on behalf of CMHS; d. Solicitors on behalf of Worksafe; and e, Other approyed information recipients.

Pad ra Signature:

MR JOHN OLL CORONER

Date: 24 Octo

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ber 2017