Deceased
Anthony James Georgiou
Demographics
31y, male
Coroner
Coroner Darren Bracken
Date of death
2016-09-12
Finding date
2022-08-26
Cause of death
Complications of methylamphetamine use in a setting of physical restraint in a man with cardiomegaly
AI-generated summary
Anthony Georgiou died on 12 September 2016 after a physical struggle with security officers at Bunnings. He had taken unpaid merchandise and was confronted by loss prevention officers (LPOs) Brenzai and Oyee. When Georgiou refused to return to the store and attempted to leave, the officers physically restrained him, leading to a struggle lasting approximately 3 minutes. Georgiou died from complications of methamphetamine use in the setting of physical restraint, complicated by underlying cardiomegaly and rhabdomyolysis. The coroner found that while force may have been justified given Georgiou's resistance, the manner of restraint was suboptimal. Critical issues included: LPOs were not adequately trained in de-escalation, monitoring for distress, or recognising positional asphyxia risks; they were unaware of the Bunnings Code of Conduct requiring disengagement from aggressive customers; and store management training did not equip managers to supervise or intervene in such confrontations. The coroner recommended enhanced training for managers, recording and auditing of LPO interactions, and refresher training incorporating de-escalation and physical intervention safety.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
IN THE CORONERS COURT COR 2016 004356 OF VICTORIA AT MELBOURNE FINDING INTO DEATH FOLLOWING INQUEST Form 37 Rule 63(1) Section 67 of the Coroners Act 2008 Inquest into the death of: Anthony James GEORGIOU Hearing Dates : 4 – 8 November 2019 Findings of: Coroner Darren J. Bracken Representation: Mr S Stafford appeared on behalf of Bunnings Warehouse Mr M Thomas appeared on behalf of Mr Abdul Brenzai Ms M Tsikaris appeared on behalf of New Security Solutions Pty Ltd Mr N Ngwenya appeared on behalf of Mr George Oyee Assisting the Coroner Leading Senior Constable Ramsey Police Coronial Support Unit Keywords Loss Prevention Officer, Shop Security Staff, Use of Force, Arrest, Physical Intervention by Security Staff, Private Security Licence
On 12 September 2016 Mr Georgiou died at the Frankston Hospital after having been involved in a dispute with security staff at the Bunnings Warehouse in Gertrude Street Frankston.
Mr Georgiou’s death constituted a ‘…reportable death…” pursuant to section 4 Coroners Act (2008) because it was unexpected, unnatural and resulted directly or indirectly from an accident or injury.
Immediately before his death Mr Georgiou lived alone having separate from his long term partner Ms Fieldhouse in 2015. Ms Fieldhouse and Mr Georgiou lived together first in Karingal and then, in about May 2013 when Ms Fieldhouse was pregnant with their first child, they moved to Carrum Downs.
In her statement on the Inquest Brief Ms Fieldhouse described Mr Georgiou as using illicit drugs occasionally and him having a degenerative back injury which arose from him having been a bricklayer and which caused him a great deal of pain. Ms Fieldhouse described Mr Georgiou as being ‘made redundant’ in 2014 from the ‘Events Company’ for which he worked and to her then being on maternity leave. Ms Fieldhouse described going back to work after their daughter was born and her maternity leave concluded. Ms Fieldhouse describes tension in the relationship in particular because Mr Georgiou was not working, and their daughter was in day-care. Ms Fieldhouse goes on to describe her involvement in the events of 12 September 2016 after Mr Georgiou was admitted to hospital including her speaking to Mr Georgiou’s father and one of his friends.
The Act requires a coroner investigating reportable deaths to find, if possible, the identity of the deceased, the cause of the death and the circumstances in which the death occurred.1
For coronial purposes, “circumstances in which the death occurred”2 refers to the context and background of the death including the surrounding circumstances. Rather than being a consideration of all the circumstances which might form part of a narrative culminating in the death, required findings in relation to ‘circumstances’ are limited to those circumstances which are proximate to the death.
The coroner's role is to establish facts, rather than to attribute or apportion blame for the death.
It is not the coroner's role to determine criminal or civil liability3 nor to determine disciplinary matters.4 Issues of ‘negligence’ are not appropriately dealt with by this court. I mention this explicitly here noting the content of written submissions made by Mr Georgiou’s family.
One of the broader purposes of coronial investigations is to reduce the number of preventable deaths in the community and to that end coroners may, report to the Attorney-General on a death,5 comment on any matter connected with the death including matters of public health or safety and the administration of justice,6 and make recommendations to any minister or public statutory authority on any matter connected with the death, including public health or safety or the administration of justice.7
Victoria Police assigned Sergeant G Richards as the Coroner’s Investigator for the investigation of Mr Georgiou’s death.
Sergeant Richards conducted inquiries on my behalf, took statements from witnesses, collated reports including from the forensic pathologist who conducted a post-mortem examination of Mr Georgiou’s body and submitted a coronial brief of evidence.
1 Coroners Act 2008 (Vic) preamble; s 67.
2 Coroners Act 2008 (Vic) s 67(l)(c).
3 Coroners Act 2008 (Vic) s 69(1).
4 Keown v Khan [1999) 1 VR 16.
5 Coroners Act 2008 (Vic) s 72(1).
6 Coroners Act 2008 (Vic) s 67(3).
7 Coroners Act 2008 (Vic) s 72(2).
I conducted an inquest into Mr Georgiou’s death over four days between 4 and 8 November
This Finding draws on the totality of the coronial investigation into Mr Georgiou’s death including the content of the Inquest Brief.
Whilst I have reviewed all the material gathered in relation to Mr Georgiou’s death, I will only here refer to that which is directly relevant to my findings or necessary for narrative clarity.
When the Inquest commenced Leading Senior Constable Ramsey read a summary of the material contained in the inquest brief.8 The circumstances surrounding Mr Georgiou’s death set out below are based on that summary augmented by the evidence given during the Inquest including Bunnings CCTV footage (“the Footage”).9
Mr Georgiou was seen to then go to the cash register and pay for a number of items but was not seen to pay for the saw blade. The Footage shows Mr Georgiou leaving the Store, stopping in a foyer area of the Store inside a pair of automatic sliding doors that lead to the car park and taking a drink from a water fountain. The Footage shows Messrs Brenzai and Oyee, store security officers, left the Store just behind Mr Georgiou and speak to him immediately he had taken his drink (10:58:08).10 Mr Brenzai asked Mr Georgiou to go back into the Store with him and Mr Oyee and to return unpaid for items he said Mr Georgiou had concealed in his clothing. Mr Georgiou declined and attempted to walk out the automatic sliding doors (10:58:25). A struggle ensued and the three men move outside the sliding doors (10.58.34) where the struggle continued. The Footage does not clearly capture what occurred
9 The Footage has no sound track.
10 Bunnings CCTV footage recorded what happened from when Mr Georgiou left the Store (Exhibit 5). The narrative in this Finding (in brackets) refers to the time stamp the CCTV footage 10:58:08 is a reference to 58 minutes, 8 seconds past 10.00am.
No objection was taken by any party to these times. A member of the public, Mr Gooch also recorded some of what happened using the camera on his mobile telephone (Exbibit 6).
outside the sliding doors but Messrs Brenzai and Oyee appear to subdue Mr Georgiou (11:00:38) and sit him down on the ground with his back against a wall. Mr P Farmer, the Store manager arrived, locked the sliding doors and called police. Police arrive at 11.28am.
Mr Georgiou appears to become unconscious, an ambulance is called and takes Mr Georgiou to the Frankston Hospital where he is admitted to ‘triage’ at 11.45am. Later that day police from the Frankston Police Criminal Investigation Unit went to the Store, obtained statements from witnesses including Messrs Brenzai and Oyee and photographed the area around the sliding doors.
The Footage shows Mr Georgiou carrying something in his left hand and his left arm is holding something yellow, which is about 25cm long against his body as he leaves the Store. This is the gas cylinder shown in photographs 11 and 12 at page 137 of the Inquest Brief and referred to by Messrs Brenzai and Oyee in their statements and viva voce evidence.
After Mr Georgiou finishes having his drink and Mr Brenzai first speaks to him Mr Georgiou still holds the gas cylinder to his body with his left arm.
Mr Brenzai stands next to Mr Georgiou and Mr Oyee behind Mr Brenzai. Mr Brenzai moves and stands between Mr Georgiou and the open sliding doors (10:58:15). Mr Oyee moves to Mr Brenzai’s right, stands opposite Mr Georgiou and takes a step or two towards him.
At (11:58:25) Mr Georgiou moves to walk between Messrs Brenzai and Mr Oyee and out the still open sliding doors. Messrs Brenzai and Mr Oyee move and stand close together in the open doorway and in front of Mr Georgiou blocking him from walking through the doorway.
Mr Georgiou appears to be still holding the gas cylinder to his body with his left arm.
Mr Georgiou pushes through between Messrs Brenzai on his right, Mr Oyee on his left and out the doorway. As he does so Mr Brenzai moves behind Mr Georgiou and puts his left arm around Mr Georgiou’s neck and Mr Oyee appears to take the gas cylinder from Mr Georgiou and place it on the ground near the doorway. I note that Mr Oyee describes doing this in his written statement. Mr Brenzai has his left arm around Mr Georgiou’s neck from behind and his feet come off the ground as he appears to hold onto Mr Georgiou. Mr Georgiou takes a step or two with Mr Brenzai on his back, Mr Brenzai regains his feet pulling Mr Georgiou
backwards against his chest. Messrs Brenzai and Oyee are able to wrestle Mr Georgiou to the ground. A vigorous struggle ensues, and Mr Brenzai can be seen to punch and knee Mr Georgiou.
Because the camera that recorded the Footage is mounted inside the foyer area of the Store and when the sliding doors are closed it is difficult to see the detail of what occurs outside, albeit the struggle involving the three men can be seen to continue.
At (11:00:25) a Bunnings employee walks out of Store into the foyer area out the sliding doors and stands in the vicinity of the struggling men. At about (11:00:55) the struggle moves to the left of the doorway making seeing what is occurring more difficult still. The Bunnings employee can be seen to be on the telephone.
At about (11:03:05) the Bunnings employee closes the sliding doors and Mr Georgiou seems to be still on the ground outside the doors to the left. Mr Georgiou’s feet can be seen at 11:03:22) and he appears to be still lying on the ground. The struggle seems to continue although it seems to have ebbed. The Bunnings employee stands in the vicinity of the three men.
At about (11:06:23) Mr Brenzai or Mr Oyee, I cannot say which stands from a kneeling position and seems to be no longer struggling with Mr Georgiou. At (11:11:54) police can be seen. At (11:18:28) Mr Brenzai walks into the exit-entry area of the Store from the Store proper and can be seen to be using the telephone. At (11:18:58) a Bunnings Employee opens the sliding doors and Mr Oyee and a policeman walk into the exit-entry area of the Store and they are joined by Mr Brenzai.
Evidence of Witnesses Dr Bouwer
“Complications of methylamphetamine use in a setting of physical restraint in a man with cardiomegaly.”11
A toxicology report12 dealing with the analysis of samples taken from Mr Georgiou at the hospital revealed methylamphetamine and amphetamine in his blood.
Dr Bouwer gave viva voce evidence that some of the ‘dot points’ that he set-out on page 16 of his report13 describing the events of 12 September 2016 were ‘acutely relevant to the cause and mechanism of death’.14 Dr Bouwer explained how the ‘at least 3 minute struggle’ between Messrs Brenzai, Oyee and Mr Georgiou led to an electrolyte imbalance that culminated in Mr Georgiou’s death.15 Dr Bouwer gave evidence that Mr Georgiou complaining of pain in his legs and hurting all over when he was sitting outside the sliding doors was relevant in as much as it was consistent with rhabdomyolysis. Rhabdomyolysis, explained Dr Bouwer, is the break-down of cells which can occur after a violent, physical, activity or a struggle the effects of which can be complicated by methylamphetamines.16 Dr Bouwer explained that in the setting of physical exercise or strenuous activity the heart rate and blood pressure go up, adrenaline and noradrenaline are released causing stress on the heart. Methamphetamine increases the release of adrenaline and noradrenaline creating more stress and has a direct effect on the heart muscle.17
Dr Bouwer described his examination of Mr Georgiou’s body revealed bilateral superior thyroid horn fractures associated with haemorrhage, facial suffusion, bilateral conjunctival petechiae which he said is usually caused by pressure applied to the ‘Adams Apple’ area of the throat. Whilst Dr Brouwer was unable to describe how much pressure would have be necessary to cause the fractures to which he referred, he explained that in younger people, such as Mr Georgiou, the structures are more cartilaginous than in older people where they are more ossified and in younger people more pressure would be required to cause such 11 Exhibit 12 Inquest Brief p.89.
13 Inquest Brief p.86.
factures.18 Dr Bouwer commented that these injuries did not appear to be immediately fatal because the deceased spoke to police after Dr Bouwer thought that they occurred. Dr Bouwer gave evidence that if these injuries inhibited breathing, then they may have contributed to the cascade of events which resulted in Mr Georgiou’s death.19 That is, a headlock, depending on how it was applied, may have caused the injuries, and if a headlock did cause the injuries and restricted Mr Georgiou’s ability to breath, that this too may have contributed to the cascade that caused his death.
Mr Oyee
Mr Oyee gave evidence in chief utilising the written statement he made to police dated 12 September 201622 and gave viva-voce evidence.
In his statement Mr Oyee recounts he and Mr Brenzai first speaking to Mr Georgiou after he left the Store (in the foyer area) and Mr Georgiou telling them that he didn’t want to come
22 Exhibit 1.
back into the shop with them. He told them that he would give them the items in his pocket and leave. Mr Oyee explained that when pressed about going with them back into the Store, Mr Georgiou told them to ‘Fuck-off’ and forced his way between them to go out the door.
Mr Oyee gave evidence of Mr Brenzai grabbing Mr Georgiou and he, Mr Oyee, grabbing the gas bottle,23 taking it off Mr Georgiou and putting it on the ground. Mr Oyee refers to Mr Georgiou throwing punches and to having been punched in the back of the neck during the struggle between the three of them. Mr Oyee referred to ‘Paul’, the Bunnings manager being present and calling the police. Mr Oyee referred to the struggle lasting for approximately three minutes after which Mr Georgiou sat up against a wall, was provided with water, was breathing heavily and slowly fell to his left side. Mr Oyee refers to police arriving less than five minutes later, speaking to Mr Georgiou and calling an ambulance and paramedics provided first aid to Mr Georgiou.
Mr Oyee was shown the Bunnings Covert Operative Instructions Code of Conduct. Mr Oyee gave evidence that his signature was on the copy of this document at p.16824 of the Inquest Brief25 but that he didn’t remember signing any such document and that the document didn’t look familiar to him.26 Mr Oyee was also shown PowerPoint presentation slides said to have been used at a Bunnings training course conducted on 19 August 2015 for covert operatives in Bunnings Stores.
Mr Oyee gave evidence that he could not remember if he had attended that training session and that the slides didn’t look familiar to him. Mr Oyee gave evidence that he didn’t recall going to any meetings of security staff or being provided any training at all by Bunnings.27
23 Whist this item is referred to as a ‘gas bottle’ it is to be noted that it is actually a metal container.
24 I note that the same document is at p.306 of the Inquest Brief.
Mr Oyee gave evidence of first becoming concerned about his own safety because Mr Georgiou was holding a gas bottle; he said; “…we talkin’ to him, and he turns to be aggressive to us. And we were fear about whatever he holding on his arm he may use against us.”28
When asked if he could have stepped away from Mr Georgiou and left him alone, he gave evidence that: “…Ah, because he had the stuff, we wanted to get the stuff off him….We couldn’t [step away from him and left him alone, to move on] because the stuff he had, we would’ve preferred that stuff off him…There wasn’t anything [stopping him physically from stepping away from Mr Georgiou] the main concern is, wanted to get the product off him…..Wanted to get all the items off him.29
When asked if he had stepped away from Mr Georgiou, he would have been safer, he gave evidence that: “Because he was so aggressive toward us, would never have, ah, turned my back and head to him.
Q. But you didn’t need - you don’t need to turn your back on him to step away from him do you?---Yes.
Q So, you could’ve stepped away from him while you were looking at him. Is that right?---That’s right. But the whole issue, your Honour, I wanted to prevent the product off him. I wanted to get the stuff off him.
Q Get the stuff off him?---And wanted to take him up to upstairs to get the paperwork.
Q To get the paperwork?---At the end of the week, you have to do the report to, ah, to
Q “I think I asked you about another page, but I want to be clear about this. Page 306 you in front of you?---Yes.
Q And that’s a document you signed? Is that right?---Yes, Your Honour. I haven’t directly signed.
Q I beg your pardon?---I haven’t directly signed.
Q Is that your signature?---It looks like my signature, but I have a doubt.
Q I’m sorry, I don’t understand?---It doesn’t look like my signature.
Q You don’t think that’s you? Yeah… Q At 168, Mr Oyee. Go to p.168---yes.
Q That’s the document you told me before, that’s your signature on it?---I say that’s not my signature, Your Honour.
Q But you told me before it was, didn’t you, or did I misunderstand that?---You probably misunderstand.31
Mr Oyee gave evidence that he had never seen the document at page 306 before and that it wasn’t his signature at the bottom and that nobody from Bunnings had told him not to engage in arguments with a customer or physically restrain an offender except in self-defence.32
Mr Oyee agreed that he remembered speaking to Mr Georgiou inside the doors of Bunnings near the water fountain and he remembered seeing that on the video played in court. He agreed that the video showed Mr Georgiou walking out the doors and that: “Q And you follow him?---When he makes his way in front of us, we – try to get him back in. You know, holding on his arm.
Q You could have let him go?---Well, we have to - we have to get out stuff back.
Q But you could – there was nothing stopping you letting him go?---But he had the stuff and all we can do (indistinct)33
Mr Brenzai give evidence in chief utilising the written statement he made to police dated 12 September 201635 and gave viva-voce evidence.
In his statement Mr Brenzai described seeing, Mr Georgiou take the label off the saw blade and put the blade in his pocket, pay for items at the cash register but does not refer to seeing him pay for the saw blade. Mr Brenzai refers to he and Mr Oyee waiting for Mr Georgiou to have his drink of water by the Store’s sliding doors, introducing himself and Mr Oyee as “…Bunnings Loss Prevention Officers…”, and telling him that they thought that he had unpaid for items in his pocket, and he would have to go with them back into the Store.
Mr Brenzai refers to Mr Georgiou having made some reference to the saw blade and told him aggressively “No fuck-off…” and walked toward the car park. Mr Brenzai refers to telling Mr Georgiou that he was under arrest, grabbing him with his right hand and Mr Georgiou struggling and then of him trying to grab Mr Georgiou across his chest.
Mr Brenzai refers to Mr Georgiou lifting him up and together with Mr Oyee being able to “…get him to the ground…”. Mr Brenzai refers to Mr Georgiou rolling around fighting and to Mr Oyee calling to other staff for the police to be called. Mr Brenzai refers to putting Mr Georgiou in a ‘headlock’ and Mr Georgiou biting him. The injuries that Mr Brenzai suffered as a result of the struggle with Mr Georgiou were photographed which photographs appear at pp.324 and 315 of the Inquest Brief. The consist of a small would on one ear and a graze on his arm. Mr Brenzai refers to Mr Georgiou saying words to the effect that he couldn’t breathe, and Mr Brenzai told him that he would let him go if he didn’t ‘throw punches or kicks’, of letting him up and a Bunnings staff member getting Mr Georgiou a bottle of water.
35 Exhibit 4.
Mr Brenzai said that he couldn’t remember when he started work with or for Mr Haider or how Mr Haider paid him.
Mr Brenzai was shown a document “Code of Conduct” , attached to AM7 ”, the same type of document that Mr Oyee was shown, this version of it ostensibly contained his, Mr Brenzai’s signature.36 The Code of Conduct sets out Bunnings’ expectations and instructions to ‘convert operatives’, that is ‘plain clothes’ security guards working at the stores looking for ‘shoplifters’ as Messrs Brenzai and Oyee were on 12 September 2016.
Mr Brenzai gave evidence that the writing on the document was not his handwriting and that the signature was not his.37 He explained that points 1 – 4 of the document had been explained to him verbally by Mr Naffah, a then employee of New Security Solutions, his then employer although he could not remember when.38 Mr Brenzai gave evidence that he had never seen the “Code of Conduct” document at page 165 of the Inquest Brief, allegedly bearing his signature.39 Mr Brenzai gave evidence that nobody had given him any documents or instructions about how he was to perform his role other Mr Naffah explaining to him points 1 – 4.
When asked about whether he recalled attending any covert operative training conducted by Bunnings, Mr Brenzai said that he had attend a meeting in the Bunnings Head Office for which was late. He initially thought that he had attended after lunch although he could not precisely remember. He said that he thought that he attended this meeting while he was working for Mr Haidar and that he, Mr Brenzai was late – he didn’t remember if he went back after lunch.
He conceded that it may have been August 2015. Mr Brenzai was taken to the PowerPoint slides at pages 281-304 of the Inquest Brief and told that these were presented to students at 36 This document, p.305 of the Inquest Brief, was a part of Exhibit AM-7 to Mr Alexander McDonald’s statement dated 31 May
37 T.116-119. And reiterated subsequently.
the covert operative training in August 2015 and asked if the slides or their content were familiar to him. He responded that he didn’t remember.
Mr Brenzai gave evidence that subsequent to the training he received as part of the requirements for him obtaining a security licence he had been to no training sessions dealing with arrest, search and release or legislation.40
Mr Brenzai was asked why he and Mr Oyee didn’t just let Mr Georgiou go to which he replied: “…We’ve had incidents in the past, your Honour, where we’ve had aggressive offenders, we’ve let then walk away. We didn’t want to sort of chase them for anything, but in particular – the particular reason that I said that at that stage where – we feared for our own safety with this gas bottle. We’ve had an incident not long out before that, where I ended up, um – ah, we were in a [indistinct] behind my back with a Stanley knife blade. So we – we used to deal with this sort of people on a daily basis, and where you don’t know who’s gonna use what towards you. And at the same time at that moment, I did ask him to no -after he refused to come to, not reach your pocket as well. That whether, I dunno if he’s gonna pull, but he obviously didn’t care and just said no with us.”41 Mr Farmer
Mr Farmer, the Bunnings employee who can be seen on the video closing the door and standing in the vicinity of the fight between Messrs Georgiou, Oyee and Brenzai. Mr Farmer gave evidence in chief by the written statement he made to police the day some three hours after the altercation and gave viva voce evidence.
Mr Farmer took no active part in the events at Bunning that day and describes the fight outside the entry-exit area of Bunnings. Mr Farmer gave evidence that Bunnings training in relation to his role in such events is to: “…My role is to very much to keep our team and our customers’ safe, um to not get involved, um, and to call police when required.”42
Mr Farmer agreed that his written statement didn’t give an accurate picture of what is recorded on the video of the altercation or of what he actually saw.43 Mr Farmer agreed that he saw Mr Georgiou pinned to the ground screaming for help but that his statement didn’t refer to him having seen that. Mr Farmer said that he had no reason for not including such matters in his statement. When put to him by Mr Stafford that he hadn’t wanted to be misleading in his statement, that he didn’t want to exaggerate, he agreed.
Mr Farmer gave evidence that the training which Bunnings had provided to him was not to get involved with Loss Prevention Officer’s (“LPO”)44 when they are dealing with those who may have stolen items from Bunnings.45 During his viva voce he qualified that by saying that in some circumstances he thought that he may get involved.46 When I put to him that Dr Zalewski had given evidence that in some circumstances store managers retained a responsibility to get involved in such events regardless of the expertise of LPO’s he said that this was contrary to his training.47
When put to him that had he thought that there was a clear danger to Mr Georgiou and that the LPO’s were acting beyond what was reasonable he would have intervened, he agreed.
When put to him that he didn’t observe any such behaviour he agreed. When put to him that he didn’t have those concerns for Mr Georgiou, he agreed.48
44 Loss Prevention Officers
Mr G Ivill
Other Witnesses Mr Stergiou
In his statement Mr Stergiou refers to urging Messrs Brenzai and Oyee to roll Mr Georgiou over on more than one occasion and he refers to Mr Brenzai or Mr Oyee telling him that they will roll him over when he stops resisting. Mr Stergiou later sees that Mr Georgiou had been rolled on to his side.
Constable Stone
on the ground on his side. Constable Stone describes speaking to Mr Georgiou who told him that his legs hurt, and he hurt all over. Constable Stone recalls the ambulance arriving, Mr Georgiou being loaded into it and Constable Black going with Mr Georgiou to hospital.
Constable Stone went to the Frankston Hospital at 3.30pm where he saw Mr Georgiou. In his statement Constable Stone describes him as groggy and giving one or two-word answers to questions put to him by nurses. Constable Stone did not speak to Mr Georgiou.
Sergeant Black
Mr Gooch
Mr Gooch refers to ‘one of the security guards’, likely to have been Mr Brenzai taking a photograph of his, Mr Gooch’s car, which made him feel uncomfortable. Mr Gooch refers to speaking this guard as a result of which Mr Gooch deleted the footage of the incident on his telephone and the guard deleted the photograph of his, Mr Gooch’s car. Precisely why or how this occurred is not clear. Mr Gooch retrieved this video and later showed it to police.
Dr A Zalewski
In the first of his reports Dr Zalewski concluded that the roles of Messrs Oyee and Brenzai, whom he described as LPO’s, were associated with high-risk physical interventions but that such risks were not reasonably managed on this occasion. Dr Zalewski lamented that there was no regulatory requirement for LPO’s to maintain and be assessed against high-risk activities including the selection of tactical options and potential use of force/arrest in the performance of their work. Further Dr Zalewski opined that while the intervention and 50 Exhibits 11 & 12 respectively.
restraint were justified the manner of intervention disclosed a lack of Messrs Oyee and Brenzai being suitably trained in relation to:
(a) Monitoring and responding to Mr Georgiou’s distress and repeated request for help because he couldn’t breathe.
(b) Adopting basic communication strategies when restraining Mr Georgiou to encourage compliance with their requests contrary to industry practise in managing resisting subjects.
(c) Understanding the risks associated with positional asphyxia during physical intervention.51
Messrs Brenzai and Oyee were originally security guard sub-contractors to Mr Haidar. As at November 2015 Mr Haidar provided contract security officers to New Security Solutions.53 Mr Haidar ceased providing security staff to New Security Solutions on 6 August 2017.54 Mr Brenzai and Mr Oyee became employees of New Security Solutions from 27 June 2016, arrangements which were formalised on, least 15 September 2016.55 As at 12 September 2016 both held Victorian Private Security Licences.56
Submissions made on behalf of New Security Solutions refer to the cause of death as set-out by Dr Brouwer as uncontroversial. I note that submissions on behalf of Bunnings refer to the coronial determination of the cause of death’ ‘as generally being taken to mean the medical cause of death’.
51 It needs be born in mind the positional asphyxia was not the cause of death but that any limitation on Mr Georgiou’s ability to breath may have contributed to, as described by Dr Brouwer, the cascade of events which lead to his demise.
55 Exhibits 6 & 7. T.190-192.
Such a conclusion is not a statement that anyone is, or may be guilty of a criminal offence, nor is it a determination of civil liability but it ‘points up’ the most significant issue in the Inquest – how the struggle involving Messrs Brenzai, Oyee and Mr Georgiou could have been avoided.
Mr Brenzai’s evidence makes clear that from when he first approached Mr Georgiou inside the sliding doors, he intended to take him back into the Store and recover the property he thought that Mr Georgiou had taken from Bunnings and not paid for. He was also determined to complete some paperwork. Mr Oyee’s evidence was to the same affect. When Mr Georgiou made clear to him that he didn’t want to be taken back into the Store, “…The male [Mr Georgiou] ignored me and said ‘No fuck off’, in an aggressive manner.
The male then kept walking towards the car park. I then grabbed him with my right hand and said ‘you are under arrest for theft you have committed an indictable offence, let’s make it easy and come back with us…. The guy just ignored us and kept walking. I was on the guy’s right side behind his shoulder and I tried to grab him across his chest with my right arm and place a leg behind him to try and get him to the ground but he was so strong that when I grabbed him he lifted me up58.
The Footage is broadly consistent with Mr Brenzai’s account of his interaction with Mr Georgiou other than perhaps Mr Brenzai’s reference to Mr Georgiou lifting him up. Mr Oyee can be seen in this video taking the gas cylinder off Mr Georgiou as the three of them move out the sliding doors. There after it was out of Mr Georgiou’s reach and not a threat.
Messrs Brenzai and Oyee used force to arrest Mr Georgiou seconds after he first spoke to him, starting the struggle between the three men. That was the fulcrum upon which events tipped 57 Written submissions made on behalf of New Security Solution Group Pty. Ltd dated 22 May 2020 [5].
58 Statement of Abdul Brenzai p.15 Inquest Brief. As much is clear also from his viva voce evidence T.106-249.
– Mr Georgiou resisted being arrested and Messrs Brenzai and Oyee countered that resistance and subdued him.
The ‘Bunnings Code of Conduct’ documents appear at pages 165 and 16859 of the Inquest Brief bearing what appears to be, respectively, Mr Brenzai’s and Oyee’s signatures as acknowledgements of them each having read and understood the Code. The Code contains 12 numbered points, number 7 and 8 of which are:
“Never attempt an apprehension unless I am 100% certain that the offender has stolen.
Never engage in an argument of any kind with a customer or physically restrain an offender except in self-defence.”
The Bunnings Code of Conduct and training setting out how LPO’s ought to deal with those at least reasonably suspected of having stolen stock from Stores. It makes clear that Messrs Brenzai and Oyee needn’t have used force to arrest Mr Georgiou.
I am conscious of dangers of undertaking a sober later assessment of conduct that occurred in dynamic stressful, circumstances imbued with at least an element of perceived urgency requiring careful consideration and am conscious of the sometimes insidious advantages of hindsight. I am conscious that Messrs Brenzai and Oyee gave evidence of their concern about Mr Georgiou assaulting them. Considering their evidence though, and the Footage Mr Brenzai’s grabbing Mr Georgiou and arresting him, aided by Mr Oyee, after Mr Georgiou made clear that he didn’t want to go back into Bunnings and began to walk off was what generated the subsequent struggle.
Mr Brenzai said that the signature on the document at page 165 is not his, that he didn’t sign such a document and that he has never seen the document before coming to court. Mr Oyee gave evidence to the same effect. When giving evidence Mr Brenzai pointed out that the purported signature on page 165 of the Inquest Brief doesn’t include his surname. Both signatures are purported to have been witnessed by Mr Haidar on 4 November 2015.
59 A clearer version is duplicated at pp. 305 & 306 Inquest Brief as exhibits to Mr McDonald’s statement which commences at p.231 Inquest Brief.
I accept Mr Brenzai’s and Mr Oyee’s evidence that they did not sign and had not seen the originals of the documents before seeing them as a part of the Inquest Brief.
Mr Brenzai gave evidence of, at some time, having attended what he referred to as a ‘meeting’ at Bunnings Head Office. He gave evidence that couldn’t remember the date of the ‘meeting’ and ‘went there’ about lunch time, had lunch with Mr Haider and wasn’t sure if he went back after lunch.
Mr Brenzai was asked questions about a Bunnings Training Session at Bunnings Head Office on 19 August 2015 and the material canvassed there and then. He was asked about whether this ‘training session’ could have been the meeting to which he referred. Mr Brenzai gave evidence that he didn’t know if that was the date, he went to what he described as a ‘meeting’ and he did not remember seeing any of the material that Mr Stafford put to him of what was canvassed that day.
Bunnings requires Loss Prevention Officers (“LPO’s”) to abide by their Code of Conduct.
Bunnings relied on Messrs Brenzai and Oyee’s employer, New Security Solutions to provide the Bunnings Code of Conduct to them. Further, Bunnings required employer security companies to provide evidence that the documents at pages 165 and 168 of the Inquest Brief were provided to LPO’s working at Bunnings. Bunnings too provided copies of the Code of Conduct to attendees at Bunnings run training courses such as the one that occurred on 19 August 2015.
Mr MacDonald, the then National Investigations Security Manager for Bunnings gave evidence that Bunnings had no evidence that Mr Brenzai or Mr Oyee attended the training session on 19 August 2015.60.
I am not satisfied that as at 12 September 2016 that Messrs Brenzai or Oyee had read or been provided with a copy of the Bunnings Code of Conduct, that either of them had attended the ‘training’ conducted on 19 August 2015 or that anyone had explained to them what it, the Code of Conduct or the training required of them including that set-out at paragraph 8 of the Code of Conduct i.e. that they were never to engage in an argument of any kind with a customer or physically restrain an offender except in self-defence.
Whilst Bunnings had the Code of Conduct documents purportedly signed by Messrs Brenzai and Oyee and relied upon them as evidence of Messrs Brenzai and Oyee knowing of their obligations under the Code the evidence is such that I am not satisfied that that Messrs Brenzai and Oyee were aware of those obligations as at 12September 2016.
Further, the provisions of the Code contain at least some ambiguity. For example, Mr McDonald gave evidence that Bunnings expect that if a person suspected of stealing goods from a Store cannot be ‘safely detained’ then such people should be ‘let go’. As much is explicit in the ‘Contractor Service Agreement’ between Bunnings and contractors post the date of Mr Georgiou’s death. When asked about whether this requirement was either included in the Code of Conduct or the training delivered on 19 August 2015 Mr McDonald explained that it was not set out in the Code of Conduct nor is it in the ‘PowerPoint slides’ used on 19 August 2015 but that it was reiterated at training sessions such as the one conducted on 19 August 2015.61
Indeed, Dr Zalewski addressed this issue in his reports pointing out the dangers that arise from using different terms interchangeably. For example, he referred to Item 8 in the Code of Conduct to be in conflict with other documents. It must of course be borne in mind that arrests and perhaps indeed ‘apprehension’ can be conducted without physical restraint. The terms of the injunction against using physical restraint seems clear enough. Dr Zalewski refers to Mr Georgiou having engaged in “…aggressive and resistive behaviour…when ‘first intercepted…. This behaviour was in the area of passive and defensive resistance as explained above and justified the use or force response.”62
This opinion is to the effect that in the circumstances, use of force may have been justified albeit that the adequacy of the manner in which that force was applied may not have been optimal. It is to be borne in mind that Messrs Brenzai and Oyee were focussed on having Mr Georgiou return to the store, return property for which he had not paid and for ‘other paperwork to be completed’. The evidence is that they could have simply allowed Mr Georgiou to leave when they first confronted him and he responded ‘aggressively’. Mr Brenzai, in particular gave evidence why he thought it unwise to allow Mr Georgiou to leave but also made clear that he considered it, at least significant, that Mr Georgiou be taken back
62 First Report of Dr Zalewski p.107 Inquest Brief.
into the Store. Significantly, the Code contains an injunction about the use of such force. In circumstances when both Mr Brenzai and Oyee63 gave evidence that when Mr Georgiou first exhibited that aggressive, passive defensive resistance the Code provides that they should have simply disengaged with him and allowed him to leave the Store. Their reasons for not doing so were that they felt that they had to ‘have paperwork done’ and retrieve the stolen goods.
Mr Brenzai makes reference to not allowing Mr Georgiou to leave because he feared him using the gas bottle as a weapon.64 This is difficult to understand and it is not clear how this fear could occur if Mr Georgiou was permitted to leave before any physical confrontation occurred.65
Mr Brenzai made clear that on 12 September 2016 he intended to arrest Mr Georgiou for leaving the Store without paying for the items he concealed.66 Mr Brenzai agreed that there were a number of points when he could have simply stepped back from Mr Georgiou and let him go but he didn’t because he, Mr Georgiou pushed him and he, Mr Brenzai, was concerned about being further assaulted by Mr Georgiou, particularly with the gas bottle and he was concerned about Mr Georgiou assaulting others.67 It is to be recalled that Mr Oyee took the gas bottle off Mr Georgiou shortly after he and Mr Brenzai confronted Mr Georgeiou and as he, Mr Georgiou walked through the sliding doors, as seen on the Footage.
In his reports Dr Zalewski referred to this case highlighting the real risk of injury or death associated with physical interventions by security staff including LPO’s in the retail sector.
He referred to there being no evidence of LPO’s maintaining a current level of competence for physical interventions through formal training. Dr Zalewski opined that Bunnings and New Security Solutions took reasonable precautions in consideration of industry practices to introduce an adequate and formalised (documented) security and safety training strategy. But that there was no evidence that either of them (or the regulator) ensured that staff maintained
competence for physical interventions in this high-risk area of work.68 I accept Dr Zalewki’s evidence.
Dr Zalewski suggested that the language across Bunnings’ training material and to the extent possible associated organisations such as New Security Solutions be standardised to ensure that terms are used consistently. That given that Messrs Brenzai and Oyee at least didn’t remember seeing these documents it cannot be said that any inconsistency had anything to do with the way that they conducted themselves on 12 September 2016 although the premise that consistency aides understanding is uncontroversial.
Dr Zalewski also referred to those with security licences not being subject to ongoing refreshment training and suggested that this was, at least, less than optimal given that licence holders are involved with real risks of injury or death arising from physical interventions. He pointed to no ‘updated training’ is required even when a licence is renewed.69 When asked about what might be appropriate in relation to ‘ongoing training’, Dr Zalewski correlates the appropriate amount of ‘refresher training’ with the specific tasks undertaken by those holding security licenses. He concedes that the security licences do not have sub-divisions for ‘crowd controllers’ who might be regularly required to ‘eject’ patrons from licensed premises and a gatehouse guard but concludes by saying that across the board half a day of face-to-face training might be reasonable for high-risk public facing roles. As a part of the general training to obtain a security licence, Dr Zalewski emphasised the significance of security personal effectively communicating with those with whom they engage especially in circumstances where a physical confrontation occurs. Dr Zalewski asserted that any refresher training should be broad and emphasise communication which affects the way people think especially under stress. He suggested that such training may make any physical confrontation ‘safer’ for all parties and perhaps allow resolution of disputes before they escalate to physical confrontation.70
I note that Mr Brenzai and Mr Oyee had been involved in confrontations with Bunnings’ customers before 12 September 2016. The nature of Messrs Brenzai’s and Oyee’s roles necessarily brings them into contact with Bunnings’ customers that will from time to time 68 Report of Dr Zalewski dated 28 December 2018.p.115 Inquest Brief.
involve antagonism. It is not clear to me if Bunnings collates, audits and analyses confrontations between customers and security staff. I can see no inherent difficulty with them doing so providing the results of such analysis to their subcontracting security companies, in this case New Security Solutions so that, for example New Security Solutions can keep a track of those of their staff who are involved in confrontations. I address this in a recommendation below.
(a) Updating its Contractor Services Agreement making it clear or clearer to New Security Solution what it expects of New Security Solutions employees and how those expectations will be fulfilled.
(b) Editing Bunnings Covert Instructions including:
(i) Standardising terms, (ii) Setting out the circumstances under which physical force can be utilised and limiting any such use to minimum force.
(iii) Making clearer the circumstances under which aggressive people suspected of taking things from the Store without paying ought to be left to leave.
(iv) Bunnings training for LPO’s to be conducted biannually and details of participants recorded.
(v) Provision of ‘Bunnings Covert Instructions, Bunnings Code of Conduct and Bunnings Convert Training material to be provided to LPO’s and recording of such provision.
Mr Georgiou’s death was a tragedy for his family as well as for all others involved including Messrs Brenzai and Oyee. Submissions from Mr Georgiou’s family are both poignant and thoughtful.
Mr Georgiou’s family’s submissions refer to negligence on a number of occasions. As I referred to above this court has no role in deciding any civil liability and so issues of negligence cannot be here decided.
Mr Georgiou’s family is concerned about Messrs Brenzai and Oyee giving evidence that they did not sign the Bunnings Code of Conduct and that they had not seen that document. It is regrettable that Mr Haider could not be located – I can take this matter no further absent further evidence.
I share Mr Georgiou’s family’s concerns that those with security licences do not undergo any refresher training. I address that issue in a recommendation below.
In the same vein as allegations of negligence, allegations of criminal conduct are not a matter for this court. The struggle between Mr Georgiou and Messrs Brenzai and Oyee was short, and the Footage does not clearly depict it once the struggle moved outside the sliding doors.
Mr Brenzai, Mr Oyee and some people uninvolved with the struggle gave evidence about it.
Analysis of occurrences such as the struggle absent the stresses present when they are occurring must be careful, and one eye kept on the effects of hindsight. Mr Brenzai and Mr Oyee gave evidence that they acted in self-defence. On the basis of the material before me I am unable to gainsay these assertions.
That it is appropriate for New Security Services to have ensured that Messrs Brenzai and Oyee had read and understood the Bunnings Covert Operative Instructions including the Code of Conduct is axiomatic. I am not able to say how and why this did not occur. The dynamic nature of changing relationships between Messrs Brenzai and Oyee on the one hand and New Security Solutions and Bunnings provides some explanation if not a reason. New Security Solutions and Bunning looking at the Code of Conduct would be entitled to accept that Messrs Brenzai and Oyee had signed it. As I have referred to above in the absence of Mr Haider, apparently at least said to have witnessed the signatures prevents this matter being taken much further.
The relationship between Mr Haider, Mr Brenzai, Mr Oyee and Bunnings was less formal than it became when Messrs Brenzai and Oyee became direct employees of New Security Solutions. That ‘informality’ was not ideal however New Security Solutions has gone a considerable way now to properly record and formalise Messrs Brenzai’s and Oyee’s employment. In times past employment of individuals in this industry was less formal than was ideal. I am again however to say whether this lack of formality was more than a circumstance surrounding Mr Georgiou’s death.
Even if the document had been signed by Messrs Brenzai and Oyee, and they had read Bunnings Covert Instructions I could not say with any degree of surety that what occurred, would not have. It is of course possible that having read those documents Messrs Brenzai and Oyee would have acted differently but on the basis of the evidence I cannot say with any confidence that this would certainly have been so.
I am unable to say what difference, if any, the New Security Standard Operating Procedures being place on 12 September 2016 would have made. That they are now in place goes some way in trying to ensure that the tragedy that was Mr Georgiou’s death does not recur. This court’s role is significantly prospectively preventative.
I am unable to be critical of Mr Brenzai or Mr Oyee for breaching the Bunnings Code of Conduct – and I am not. Their evidence is that they were simply not aware of it. As I have referred to above, even had they been, as the evidence currently stands, I am not clear that such knowledge would have made any difference to what happened. There is evidence that would support Messrs Brenzai and Oyee or either or both of them arresting Mr Georgiou. I am unable to say that the force they used was unreasonable in the circumstances. Mr Georgiou’s medial conditions and his use of illicit drugs were, according to Dr Brouwer, each a cause of his death.
There seems to be no controversy that Messrs Brenzai and Oyee didn’t complete a full day’s training on 19 August 2015. There is however insufficient evidence for me to conclude that if such training had occurred that Mr Georgiou would not have died as he did. I have considered a number of issues in this light. Such considerations are precisely the task of this Court. As I refer to above considerations of civil or criminal liability are not the focus of this court.
Bunnings’ training of Mr Farmer did not include training equipping him to tell LPO’s what to do if he thought it necessary. Dr Zalewski considered that despite LPO’s being specialists in their role, Mr Farmer, as a senior Bunnings manager present, retained a responsibility to manage the LPO’s. I set out a recommendation below that Bunnings specifically provide managers such as Mr Farmer with training will allow him to make assessments of situations such as the one that confronted him on 12 September 2016 and if he considers it appropriate then and there to instruct LPO’s.
Written submissions made to the Court by Bunnings largely deal with recommendations that the evidence in this inquest suggested might have been usefully made. I commend Bunnings for proactively addressing raised in by the Inquest.
Having investigated Mr Georgiou’s death and having held an inquest pursuant to 67(1) of the Coroners Act (2008), I find that:
The identity of the deceased was Anthony Georgiou born 2 February 1985;
(i) On 12 September 2016 at The Frankston Hospital, 2 Hastings Road, Frankston, Victoria; (ii) as a result of complications of methylamphetamine use in the setting of physical restraint in a man with cardiomegaly; (iii) in the circumstances set out above.
RECOMMENDATIONS Pursuant to section 72 of the Act I recommend that:
Bunnings consider including in their training of Store Managers instruction in relation to the supervision of LPO’s particularly when such Officers are involved in a physical confrontation with a customer. Bunnings consider include in such training instruction about when Store Managers should become directly involved in actively managing LPO’s involved in any such confrontation.
Bunnings record the details, including the names of LPO’s involved, of all interactions between LPO’s working at Bunnings Stores and customers. That Bunnings periodically audit those records, reviewing the performance of LPO’s and provide a copy of those audits and reviews to the direct employers of LPO’s operating at Bunnings Stores.
That the Bunnings Training for LPO’s as referred to in paragraph 92 of this Finding include the kind of ‘refresher training’ recommended by Dr Zalewski and set out in his reports provided to the Court in this Inquest. (Exhibits 11 and 12 of this Inquest).
PUBLICATION Pursuant to section 73(1) of the Act, I order that this Finding be published on the Coroners Court of Victoria website in accordance with the rules.
DISTRIBUTION I direct that a copy of this finding be provided to: Mr A Georgiou Mr Georgiou’s brother Mr Alexander MacDonald National Investigations and Security Manager Bunnings Group Limited Mr G Atkins Solicitor Solicitor for Bunnings Group Ltd.
Mr Alan G Merheb Director New Security Solutions Pty. Ltd. C/O Clyde and Co Solicitors Ms Angela Fieldhouse Ex-Partner of Mr Georgiou Sergeant G Richards Coroner’s Investigator Ms L Taylor Peninsula Health Further: Noting that Victorian Government conducted a review of Victoria’s private security industry resulting in a report entitled ‘Review of the Private Security Industry’ dated 2021 which, amongst other things, recommended (Recommendation 8) that prior to licence renewal, applicants should be required to undertake refresher training with an LRD28
approved RTO. I direct that a copy of this Finding and Exhibits 11 and 12 of this Inquest be provided to the Secretary of the Department of Justice and Community Service to inform that recommendation.
Signature: ______________________________________ Coroner Darren J. Bracken Date: 26 August 2022 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an inquest. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.
Natasha Stojkoski, a 38-year-old sales assistant at The Good Guys, sustained a workplace injury in October 2018 involving a Work Assisted Vehicle incident affecting her back, shoulders and neck. Subsequently, she reporte…
A 44-year-old woman died from pulmonary thromboembolism 27 days after sustaining a Weber B ankle fracture from a fall. She was managed conservatively with a CAM boot then below-knee cast, with progressive immobilisation …
Simon Gaskill, aged 50, was found deceased in sand dunes at Ocean Grove Beach in April 2022 after sleeping rough for months. He had been discharged from hospital in December 2021 following treatment for severe alcohol wi…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries are for educational purposes only and must not be treated as legal documents. Report an inaccuracy.