Inquest into the Death of Shionah Violet Teneille CARTER

Coroners Act, 1996 [Section 26(1)] Western Australia

RECORD OF INVESTIGATION INTO DEATH Ref No: 25/14 I, Evelyn Felicia Vicker, Deputy State Coroner, having investigated the death of Shionah Violet Teneille CARTER, with an Inquest held at Perth Coroners Court, CLC Building, 501 Hay Street, Perth on 17 June 2014 find the identity of the deceased was Shionah Violet Teneille CARTER and that death occurred on 15 August 2010 at Unit 2, 21 Ottawa Crescent, Beechboro, in the following circumstances - Counsel Appearing: Ms K Ellson assisted the Deputy State Coroner Mr P Slater appeared for the Commissioner of Police Table of Contents Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 1.

INTRODUCTION In the early hours of 15 August 2010 Shionah (Shoni) Violet Teneille Carter (the deceased) died as the combined result of a number of injuries sustained during a prolonged altercation with her partner. She was 26 years of age.

On 22 December 2011 her partner pleaded guilty to the murder of the deceased and was sentenced to life imprisonment with a minimum of 15 years to be served before becoming eligible for parole.

BACKGROUND The Deceased The deceased was born on 15 October 1983 and was the oldest of five siblings comprising two boys and three girls.

She enjoyed school and enjoyed English.

Her mother described the deceased as a wonderful individual, always calm, happy and robust and a great help with her younger siblings.

The deceased was passionate about her heritage, loved all people and touched everyone with whom she came into contact.

The deceased stayed at school until year 11 and thereafter her mother encouraged her to attempt to continue her Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 2.

education. She went to Curtin University and completed the Indigenous Bridging Course in which she did very well.

The deceased then travelled to One Arm Point to visit with her father for two and a half years and whilst there ran the local store.

She later returned to Perth to be with the rest of her family.

She trained as a Barista and worked in numerous cafes, while doing a laboratory diploma course with her mother with the intention of obtaining further qualifications in the area of forensics. Unfortunately she did not complete that line of education.

The deceased had been in a relationship with her partner for about 18 months before her death.1 They had lived in a defacto relationship since at least late 2009, and there were recorded by police domestic violent issues between them.2 In the period before her death the deceased and her partner had been living in a two bedroom unit at 21 Ottawa Crescent, Beechboro, with her partner’s older brother, for whom her partner was a carer.3 1 Ex 2, tab 26 2 Ex 2, tab 11, Ex 7 & 8 3 Ex 2, tab 26 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 3.

The deceased was at home without her partner for periods of time and was annoyed he left her alone so much.4 Her family also noted the deceased to be quiet, and that she seemed to have withdrawn from them during her time with her partner.5 In the days prior to 15 August 2010 the deceased’s partner had been partying and using methylamphetamines intravenously.6 The Events The deceased was at home at Unit 2, 21 Ottawa Crescent continuously during the afternoon of 14 August 2010 to the time of her death sometime between 3:21am and 4:23am on 15 August 2010.7 In the early afternoon of 14 August 2010 the deceased was at home with friends when members of her partner’s family arrived to visit. They stayed until the early evening by which time the deceased was left on her own and her partner had still not returned.8 The precise times at which the deceased’s partner came and went during the evening of 14 August 2010 are difficult to establish due to conflicting chronologies however, it is clear 4 Ex 2, tab 10, 26, 39 5 Ex 2, tab 48 6 Ex 9 7 Ex 2, tab 26, 1, 7, 46 8 Ex 2, tab 26 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 4.

he was at home during part of the evening between visiting social venues.9 One witness has him at the unit between, very roughly, 6pm to 8pm, during which time there was an altercation with the deceased.10 The deceased’s partner had arrived at their home with others. They stayed for a period of time during which the deceased and her partner argued and her partner was heard to “rough handle” and “push her around”.11 Her partner asked the deceased before they all left whether she wanted to go to a party with them, but she declined.

At 7:28pm on 14 August 2010 Telstra recorded a 000 call from the fixed line telephone service address at Unit 2, 21 Ottawa Crescent, Beechboro. It was of no duration and did not progress to the emergency service answering point.12 At 7:53pm on 14 August 2010 Telstra recorded an 89 second 000 call from the same fixed line telephone service address. This call was answered by an operator but, due to there being no vocal response, was sent to an automatic interactive voice response system. The whole recording reveals sounds of violence, and (?) crying, in the background. It is unlikely this would have been audible to 9 Ex 2, tab 10, Ex 9 10 Ex 2, tab 1 11 Ex 2, tab 1 12 Information obtained from Telstra’s Emergency Service Answer Point Support on 23.06.2014.

Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 5.

the operator before the call was switched to the automatic system, and then terminated due to a lack of response.13 The deceased’s partner visited both a football club gathering and later a party at a community hall during the evening and into the night of 14-15 August 2010. He drank at both venues and was suspected of also being drug affected.14 The deceased’s partner came and went from both venues and 21 Ottawa Crescent with different persons during the night.15 During his time at the party the deceased’s partner was involved in a fight with others which left him angry.

At some time after midnight on 15 August 2010 a cousin of the deceased’s partner was looking for him to find out where the party was her partner was visiting. The cousin and a relative visited 21 Ottawa Crescent to ask the deceased where her partner was.16 The cousin’s relative observed the deceased and the cousin talking at the front door. Both were in view the whole time and nothing of note occurred.17 The cousin and relative were about to leave when the deceased’s partner arrived back from the party in an agitated state and saw the car outside his home.18 The deceased’s partner then declined to 13 Communication from Telstra’s Emergency Answer Point Support dated 23.06.2014 14 Ex 2, tab 10 15 Ex 2, tab 1, 8 & 46 16 Ex 2, tab 1, 8 & 46 17 Ex 2, tab 46 & 48 18 Ex 2, tab 1, 8 & 46 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 6.

return to the party with the others and stayed at the unit with the deceased. Before the others left they heard the deceased and her partner arguing.19 The deceased and her partner continued to argue and the deceased was accused of being unfaithful to her partner.20 The neighbours in Ottawa Crescent reported hearing and seeing vehicles coming and going during the early hours of the morning.21 During the course of that early morning, following his return from the party, the deceased’s partner assaulted the deceased. In his video record of interview22with the police the deceased’s partner stated he struck her in various rooms in the unit with various objects. The ongoing assault was later confirmed by forensic evidence located in the unit which included objects, bodily matter and matching injuries on the deceased.

At 3:21am on 15 August 2010 a Telstra Emergency Service operator received a call from the fixed line service address at the unit in 21 Ottawa Crescent, Beechboro. A male caller asked the operator if he could be connected with police and identified the unit number to the operator.

19 Ex 1, tab 46 20 Ex 9 21 Ex 2, tab 37 & 46 22 Ex 9 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 7.

The Telstra operator connected the caller to the police and the call was answered by First Class Sergeant Andrew Bell (Bell), one of the supervisors at the Police Operations Centre

(POC).

Initially there was no response to Bell’s inquiry and Bell asked the Telstra operator if there was anything in the background. The line was still open, and then the sound of a voice and moaning can be heard in the background.23 The male caller came back online and the Telstra operator would have then disconnected from that call. The male caller asked for an ambulance. Bell asked what was happening and the caller said there had been an argument with the “missus” and he wanted an ambulance.

Bell advised the caller he had been connected with the police and tried to identify what was happening by using the caller line identification (CLI) information transferred from Telstra to his screen in POC. The caller identified himself as “Shane Patterson”, not consistent with the CLI information before Bell, and when asked by Bell about the person making the noise in the background he stated it was his “missus”. The sound of moaning and whimpering continued in the background.

23 Ex 1, tab C, tab 1 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 8.

When Bell attempted to get “Shane” to identify where he was so he could send help, the response was a reference to a “party” at “Altone Park”, again inconsistent with the CLI information, and the male caller then hung up.

Bell immediately called back on the CLI information on his screen but was unable to re-establish contact. No further action occurred at that time with respect to police involvement.

Neighbours confirmed hearing arguing intermittently at about 2:40am and again after 3:30am. Someone was also heard “whimpering” from time to time between thumping sounds.24 The deceased’s partner alleged the deceased, as a result of the prior assaults, was covered in blood and so went to have a shower following which she lay on the bed.25 He then alleged they had consensual sex, including anal penetration, during which time he realised she was no longer breathing.

The deceased’s partner told police he tried to revive the deceased by performing CPR and then went to the neighbours asking for help.

24 Ex 2, tab 39 25 Ex 9 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 9.

Police received 000 calls from various neighbours26 after about 4:10am and at about 4:15am on 15 August 2010 police Constables (Baldwin and Greenshaw) were tasked to attend 21 Ottawa Crescent, Beechboro.

The two police constables located the deceased’s partner in the driveway of the units at about 4:23am in a distressed state. He advised the police officers he needed an ambulance, not police, but when the police officers tried to assess his condition he stated he thought “she’s dead” and told them she was “in unit 2”.27 Additional police arrived at that time and Baldwin and Greenshaw left the deceased’s partner with those police officers while they went to find the deceased.

They located the deceased on a bed in a bedroom, lying on her back. She was not breathing and unresponsive. The police officers requested the attendance of an ambulance and started cardio-pulmonary resuscitation (CPR). At no time did the deceased respond to the police. The ambulance officers arrived and confirmed the deceased had died.

The two police officers’ descriptions of both the scene in the unit, and the deceased, are harrowing.28 26 Ex 2, tab 28, 33 27 Ex 2, tab 4 & 16 28 Ex 2, tab 4 & 16 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 10.

The deceased’s partner returned positive results for alcohol, cannabis and methylamphetamine in his blood from samples taken from him that morning.

The deceased’s partner participated in a record of interview with the police29 on the afternoon of 15 August 2010 at Midland Police Station and admitted assaulting the deceased on numerous occasions during the evening of 14 through to 15 August 2010. He gave a very confused account of the events over the previous 24 hours which was largely blamed on his state of intoxication during that time.

He did not mention any calls to any emergency services.

Later during the course of the investigation, when police became aware of the 000 calls, the deceased’s partner declined to participate in any further interview with the police about their ongoing investigations.

He pleaded guilty to causing the death of the deceased on an agreed statement of material facts30 and was sentenced on 22 December 2011.

ISSUE FOR INQUEST The sole issue to be examined during the course of the inquest was whether the actions of Bell, by failing to comply 29 Ex 9 30 Ex 1, part A, tab A 2 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 11.

with established police protocols and procedures following the 3:21am 000 call, contributed to the death of the deceased, pursuant to section 22(1)(b) of the Coroners Act 1996.

It is undisputed the deceased’s partner caused her death (section 53(2) Coroners Act 1996).

POST MORTEM EXAMINATION31 The post mortem examination of the deceased was carried out by Dr Jodi White of PathWest. She both attended the scene on the afternoon of 15 August 2010 and performed the autopsy at PathWest on 17 August 2010.

At the scene Dr White noted the deceased to be lying on her back, towards the end of the bed, with her knees and lower legs dangling off the bed, as was her right arm. She was clothed with her upper garments pushed up above her abdomen. There were obvious soft tissue injuries to the deceased’s lower limbs and head area, with her hair matted with blood. There was also bruising and swelling to various parts of her body.

Following the medical examination on 17 August 2010 Dr White summarised her findings as follows;

1. Soft tissue injuries to the scalp, face, trunk and limbs; 31 Ex 1, part B, tab A 8 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 12.

2. a small amount of aspirated material with congested changes in the lungs;

3. a confirmed pregnancy;

4. soft tissue injuries to the pelvic organs;

5. soft tissue injuries to perineum.

Dr White instituted further investigations in an attempt to clarify the mechanism by which the deceased had died.

These investigations included neuropathology, toxicology and histology.

Neuropathology was undertaken by Dr Vicki Fabian32 and revealed a traumatic brain injury. This comprised recent contusions to the frontal lobe and the cingulate gyrus, recent contusions and lacerations to the left temporal lobe, haemorrhages in the splenium of the corpus callosum, superiorly, with wide spread amyloid precursor protein (APP) positive neurites and axonal spheroids in the corpus callosum.

As a result Dr Fabian gave her final diagnosis as Traumatic brain injury:-

1. Multiple contusions of both cerebral hemispheres and lacerations left temporal lobe occurring approximately 6 hours prior to death.

2. Haemorrhages in the corpus callosum.

3. Widespread amyloid precursor protein (APP) positive neurites and axonal spheroids in the corpus callosum. These features are in keeping with a mild head injury of at least 7 hours and up to 4 days duration which may 32 Ex 4 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 13.

be associated with concussion (transient loss of consciousness).

With respect to the timing of the injuries in relation to the deceased’s death Dr Fabian clarified she believed the contusions and lacerations occurred approximately six hours prior to the deceased’s death.

With respect to the haemorrhages in the corpus callosum Dr Fabian was able to say the APP stain was negative adjacent to the haemorrhages which would time those haemorrhages as occurring approximately 30 minutes to 1.75 hours prior to her death.

Dr Fabian corrected her original timing for the injuries which did show APP staining to 2.5 to 5 hours prior to death and possibly up to 3 days duration.

On review of her findings Dr Fabian stated;

1. The neuropathology findings are insufficient for a cause of death.

2. All the changes reported in the brain can have occurred less than 6 hours prior to death.

3. The neuropathology findings may be associated with concussion and loss of consciousness.

4. The wide spread APP positive neurites and axonal spheroids in the corpus callosum indicate this injury may have occurred at least 2.5 to 5 hours prior to death and up to 3 days duration.

Overall, while the neuropathology cannot account for the deceased’s death alone, it is indicative of a prolonged and Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 14.

sustained battering of the deceased in the hours before her death which rendered her very vulnerable to further health difficulties without medical intervention.

Toxicology indicated a small amount of tetrahydrocannabinol in the deceased’s blood at the time of death with no alcohol or other common drugs.

Histology of the tissues from the deceased’s various areas of injury, by Dr White, revealed areas of fresh haemorrhage with early inflammatory response, indicating the deceased incurred some of her injuries prior to death. The injuries showing an inflammatory response tended to be those on her upper body. Other injuries appeared to show no inflammatory response and are consistent with being inflicted upon the deceased at the time of her death, or shortly thereafter.33 The injuries showing no inflammatory response were those on the deceased’s lower body.

At the conclusion of all the medical investigations Dr White was unable to provide a definitive cause of death on the post mortem findings alone and it was recorded as “Unascertainable” for the purposes of the record.

In evidence, Dr White gave her professional opinion, based on her experience, her examination of the deceased and 33 t 17.06.14 p65-67 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 15.

knowledge of the scene, the deceased had died as a result of positional asphyxia during a sexual assault.

Dr White pointed out that although the brain injuries were not sufficient to cause the deceased’s death in and of themselves, they would have rendered the deceased concussed and probably unconscious, which would have left her vulnerable to asphyxia, whether she was placed face down or upon her back for sexual activity.34 In a face down position, while becoming unconscious, the deceased would have been unable to protect herself by moving her face and so would have asphyxiated; and if she had been on her back whilst unconscious, Dr White described how in the unconscious state, her tongue would relax and occlude her trachea and so cause her to asphyxiate.

The deceased’s pelvic and anal injuries indicated those were likely to have been inflicted during some sort of sexual assault, but due to the lack of inflammatory response would indicate those were close to or after the time of death. The outcome of that information would indicate the deceased was being sexually penetrated in some way at the time she died, which would make it consistent with asphyxia arising out of unconsciousness or concussion in conjunction with her earlier brain injuries.35 It is also consistent with her partner’s version of events, but does not support his assertion the sexual activity was consensual.

34 t 17.6.14 p78 35 t 17.6.14 p71-74 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 16.

In addition, Dr White after her viewing of the deceased at the scene and the post mortem examination thought it unlikely the deceased had showered herself prior to the sexual penetrations. The type and extent of injuries to the deceased’s pelvic and anal area made it unlikely the deceased was consenting. Whether she was unconscious /concussed is an additional issue.

The ability to time the different injuries the deceased incurred is relevant to the survivability of the deceased had there been a response to the telephone call received by the Police Assistance Centre (PAC) at 3:21am (the telephone call) on 15 August 2010.

From an assessment of the injuries in their entirety and the fact the deceased can be heard moaning in the background of the telephone call, it is clear she was alive at that point.

It is likely she had already incurred most, if not all, of the upper body and traumatic brain injuries which could render her concussed and unconscious.

Dr White had this to say about concussive head injuries; “When you have concussive head injuries - these are ones you see on the football field, so people normally lose consciousness straightaway and then they - you know, after a few seconds or several minutes they will wake up. I think it can be up to about 30 minutes where you can stay unconscious for. So you can get – so she may have sustained Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 17.

a blow to the head which has caused her to lose consciousness just before - leading up to the period in which she died, or she may have lost consciousness earlier and regained consciousness. There are reports in the literature of people who’ve had a head injury like this and then they go on

• they sort of wake up and later, like, over hours or minutes later, they actually deteriorate again and can lose consciousness again. So some of them are to do with the fact that they’ve actually got a more serious head injury within the cord, so where your breathing and heart centre is; and some of them get to a bleed over the head, a spontaneous bleed; and other people, they just don’t know why it happens. So there are a number possibilities in her case.”36 While it is speculation it would fit the scenario of the deceased becoming unconscious and her partner attempting to call for assistance, the deceased coming around and moaning, as can be heard on the call, which leads her partner to hang up believing she is now recovered.37 It would seem to be following the telephone call, and before the time the deceased’s partner sought help from the neighbours, that he inflicted the injuries to the deceased which showed no or very little inflammatory response.

These would be consistent with her dying as a result of asphyxia during the course of those injuries which appear to be associated with sexual penetration and her positioning.

36 t 17.6.14 p74 37 t 17.6.14 p75 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 18.

Dr White was quite clear the deceased’s upper body injuries generally preceded the injuries of the deceased’s pelvic and anal area.

Overall the scenario is consistent with a prolonged beating causing traumatic brain injury, possibly at different times, before the 3:21am telephone call. The deceased then suffered further assault after the 3:21am telephone call which resulted in her death, quite rapidly, due to asphyxiation and cardiac arrest. Death from asphyxiation can occur in minutes, and the longer the downtime (time without oxygen) before effective resuscitation, the less chance there is of sustainable recovery.38

000 CALLS Calls made to 000 are initially responded to by a Telstra emergency call person (ECP) who establishes which emergency service organisation (ESO) is being requested by the 000 caller. At the same time the ECP can view, on a computer screen, the caller line identification (CLI) details from which the 000 call is made. In the case of a fixed line service this comprises the address of the phone service used by the 000 caller and the name of the person to whom the fixed line service is registered.

Once the caller identifies which ESO is required, the ECP transfers the call to that ESO and remains online until a 38 t 17.6.14 p75 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 19.

conversation has been established between the 000 caller and the ESO operator. The ECP then leaves the connection and the call continues between the 000 caller and the ESO operator. Both the ECP and ESO 000 calls are recorded.39 Where the 000 caller requests police as the ESO, the call is transferred to the PAC by the ECP and an identifying sequence is provided to connect the calls. The Police call taker then responds to the 000 caller and, once connected, the CLI information from Telstra appears on the police call taker’s computer screen.

POLICE ASSISTANCE CENTRE (PAC) Evidence was heard from Superintendent Lance Martin, 40Divisional Officer in charge of the Police Communications Centre (PCC) since 2013.

Superintendent Martin explained the PCC comprises the Police Operations Centre (POC) which facilitates police tasking, and the Police Assistance Centre (PAC) which receives both 000 emergency calls and calls to the general police assistance number, 131444. The communications centre operates 24/7.

All policy, procedure and associated guidelines regarding the handling of 000 calls is contained within the 39 Communication Telstra to Coroners Court 8.07.2014 40 Ex 2, tab 51, t 17.6.14 p30-50 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 20.

communications division knowledge database and all call takers in PCC are trained in those policies, procedures and guidelines.

In 2010 PAC was staffed by both sworn and unsworn police officers, however, those responding to 000 calls were usually sworn police officers. Bell was the supervisor of a pod of call takers. Bell was an experienced and well respected police officer in his role.

The policies, procedures and guidelines in place in 2010 required a 000 call taker to attempt to establish the difficulty faced by the caller, the location of the caller and/or the location of the problem and make an assessment of the need to task police officers or other services to attend to the reason for the call.

The CLI assisted the call taker with the veracity of the antecedents of the caller, but could only establish the location from which the call was made. Background information could provide assistance as to whether the call related to the location from which the call was made, or was a hoax.

The procedures for taking 000 calls have not changed since

2010. The environment in which it is done has, in an attempt to improve the quality of the service.

Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 21.

Where background information raises a concern for the welfare of any person then it would be normal for the call taker to populate a computer screen with relevant information to assist in tasking a police vehicle to attend at the location of either the call or the problem. The computer screen can also be updated as more information becomes available.

In the event a call is disconnected, the call taker uses the CLI in an attempt to re-establish contact with the 000 caller. If that is unsuccessful and the call taker is of the view there is a problem which requires the attendance of police, or other services, then the call taker should populate the screen with the CLI information and dispatch police to the identified location. In the case where the background noise or the information provided indicates a problem with a person’s health or welfare, it would be usual for the call taker to also request the attendance of an ambulance to support the police dispatched to the location.

In the current case the background noise to the 000 call from 21 Ottawa Crescent at 3:21am on 15 August 2010 clearly identified a person in distress, as did the comments of the caller (the deceased’s partner) who had by then switched to requesting an ambulance, although giving incorrect information as to his name and confusing information as to a location.

Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 22.

On that call being disconnected Bell reacted promptly by attempting to recall the number from which the call had been made. He had already asked the caller about the person in distress in the background to the call. When Bell was unsuccessful in reconnecting the call, he did not populate a computer tasking screen for dispatch of a police vehicle to the CLI address. Nor did he request the attendance of an ambulance at the same location.

The responsibility for managing 000 calls was reassigned from POC to PAC in November 2013 with senior police responsible for overseeing all call taking including the 000 calls. A quality assurance process was introduced with immediate feedback. A system for identification of missed opportunities for improvements in the handling of 000 calls was also implemented. The quality assurance has allowed senior police to identify skill gaps and training issues, or changes required in the communications knowledge database to develop and ensure best practise.

In addition the introduction of more sophisticated computerisation in some police vehicles has allowed the continuous updating of information to police officers in vehicles tasked to attend various incidents.

It is clear there has been a dedicated attempt to improve both the training and management of 000 calls to PAC.

However, it is not clear the revised procedures would have Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 23.

prevented the mistake made by the call taker in the early hours of 15 August 2010.

I accept Bell was a dedicated and experienced call taker. He was also a supervisor and had the required skills and training to have followed accepted procedures which should have seen a computer screen populated with the CLI information, the details of the call and so resulted in the tasking of a police vehicle to attend the CLI address.

INVESTIGATION Once the failure of Bell to task and dispatch a police vehicle to the CLI location following the 3:21am call on 15 August 2010 became apparent during the investigation of the death of the deceased, Bell’s actions were investigated by the Internal Affairs Unit of WAPol. That investigation was conducted by Detective Sergeant Craig Wasley.

In evidence Wasley41 described how Bell had, during the course of the telephone call, followed accepted procedures for obtaining as much information as he could from the 000 caller. The fact he was provided with a name inconsistent with the fixed line service registered owner did not detract from the fact the call was being made from that location.

This is despite the fact the caller provided location information which did not appear to correspond to the 41 t 17.06.14 p10 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 24.

CLI information. It was clear from the call itself there was a person whose welfare was in doubt located at the CLI address.

Bell had requested information about that person and had been advised it was the 000 caller’s “missus” and she must have been located at the CLI address. On disconnection of the call by the 000 caller, Bell had acted appropriately and attempted to re-establish the line, but was unsuccessful. At that stage, Walsey stated Bell should have populated the computer aided dispatch (CAD) system to direct a police vehicle to the address on the CLI information as a starting point for location of the call where there was a person in distress.

In Bell’s interview with the Internal Affairs unit he was unable to either recall the telephone call in question or his reason for not then creating a “job” for police to attend at the CLI.

Bell listened to the recording of the call and was clearly distressed he had not responded appropriately. While there are hoax calls to 000 ESO, the background moaning in the given call was something Bell acknowledged required he act in accordance with the protocols regardless of the potential for hoax callers. He was unable to explain why that had not occurred and was clearly distressed at his failure to task either a police vehicle, or ambulance to the CLI address. It Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 25.

was generally accepted police would have been able to attend at the CLI address.

As a result of the Internal Affairs investigation Bell was stood down from duty and subjected to a Commissioner’s “loss of confidence notice”. Ultimately due to his experience and previous exemplary record, Bell was returned to operational duty, however has since retired from the police force. At no time did Bell attempt to minimise his actions or evade responsibility for what had occurred. The fact he also had significant personal problems at the time of his failure to respond appropriately was not a matter utilised by Bell for sympathy.

The Internal Affairs investigation established neither of the Telstra 000 calls of the previous evening, 14 August 2010, had been put through to POC. It is clear from information provided by Telstra those calls did not get put through to police, or any EOS; and the only call of any duration had been switched by the ESP to an automatic response function which was not further activated.

Evidence was also heard at the inquest from Professor Jacobs the Clinical Services Director of St John Ambulance WA. Professor Jacobs is a professor of resuscitation and pre-hospital care at Curtin University. Aside from being provided with documentation with respect to the 3:21am telephone call, Professor Jacobs was also provided with Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 26.

other documentation in an attempt to assess whether St John Ambulance paramedics, had they been dispatched to 21 Ottawa Crescent shortly after 3:21am on 15 August 2010, would have been in a position to save the deceased’s life.

From the documentation Professor Jacobs was unable to determine which of the deceased’s injuries were inflicted before or after that telephone call.

However, Professor Jacobs was also in court when the court was closed for the playing of the recording of the 3:21am telephone call. The background to the call contained groaning and moaning. Professor Jacobs was able to say it was clear the deceased was in distress at that point in time.

He was unable to say whether that was purely psychological, emotional, physical or as a result of trauma.

Professor Jacobs indicated at 3:21am it was clear the deceased was in one of those types of distress, but could not determine what had occurred between that time and the call made at 4:13am to St John Ambulance Service. That call was for a patient who had collapsed and was in apparent cardiac arrest and non-responsive.42 Professor Jacobs pointed out a call could have been made directly to St John Ambulance at 3:21am and the St John 42 t 17.6.14 p53 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 27.

Ambulance call takers are also trained to take into account background noise. It was his view the St John Ambulance Service would have responded to the telephone call of 3:21am on 15 August 2010 by dispatching an ambulance, as the police would usually do in accordance with their protocols.

In the road conditions at that time, which Professor Jacobs had been able to establish by referring back to St John Ambulance usage, he believed the ambulance response time would have been less than 10 minutes. One can assume police would have taken a similar amount of time, not knowing at that stage, the level of priority. Professor Jacobs said for an ambulance at priority 1 the response would have been a few minutes. The traffic conditions at 3:21am in the morning are such that a priority 1 response would not have had a significant difference in the response time of any ambulance.

Professor Jacobs was unable to say whether an ambulance dispatched at 3:21am and arriving within the next 10 minutes would necessarily have been able to save the deceased’s life, assuming she was still alive, depending upon her physical condition at that time.

All that can be said with certainty was that at the time of the 4:13am call to St John Ambulance the deceased was reported as collapsed and in cardiac arrest. She was Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 28.

deceased by the time paramedics arrived at 4:23pm. She was clearly deceased at the time the police arrived. Police attended prior to the St John Ambulance.

From Dr White’s evidence it was also clear that once the deceased was in cardiac arrest, it was impossible to say whether she could have been revived. From the evidence of the neighbours it is impossible to determine when exactly the deceased collapsed and stopped breathing. It must have been before 4:10am by which time her partner was running up and down the street seeking assistance.

In his record of interview he said the deceased had already collapsed by this time. No one will ever know when exactly that occurred. The best we can say is that it was clearly after 3:21am and it would seem likely, on the whole of the evidence, the deceased’s final collapse occurred sometime between 3:30am and 4:00am on 15 August 2010.

Any intervention during that time may have saved her life, but it is impossible to say when exactly she would have been revivable following her collapse, and how long, if at all, after her collapse she would have survived as a sentient being. Had police been dispatched following the 3:21am phone call it is likely they would have attended the address, although not the unit number on the information provided, around 3:30am. It was roughly at that time the neighbours indicated there were further sounds of an altercation from Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 29.

the deceased’s home. Presumably the deceased was still alive at that time, although in what state is unclear. Police are trained in competent CPR.

On the whole of the evidence it is clear the deceased died after the 3:21am phone call, but before 4:10am. From the forensic evidence it would appear she received her head injuries prior to 3:21am which, although not life threatening in themselves, were likely to have caused unconsciousness/concussion which may have been intermittent. This rendered her vulnerable to positional asphyxia and cardiac arrest when man handled during any sexually directed assault. This was certainly before 4:10am.

From the above it is clear the deceased’s partner’s actions both caused and contributed to her death. However, it is possible medical intervention between 3:30am and 4:00am may have prevented her death. Had Bell dispatched police or an ambulance to the address on the CLI in accordance with police policies and procedures it is possible the deceased’s death could have been prevented.

It is not clear, however, as to whether the deceased’s overall prognosis by that time would have been for a sustainable recovery, depending upon the level of further assault and injury she had incurred. The post mortem examination indicates this was significant and included a level of Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 30.

aspiration which would have impeded effective respiration and re-oxygenation.

CONCLUSION AS TO THE DEATH OF THE DECEASED I am satisfied the deceased was in a defacto relationship with her partner of at least twelve months duration. During that time she had been involved in previous altercations with her partner but had not sought assistance from her family or others.

In August 2010 the deceased and her partner were staying with her partner’s older brother at 21 Ottawa Crescent in Beechboro.

During the day of 14 August 2010 the deceased was at home and her partner was not present until later in the day.

The deceased was unhappy at being left on her own so much and on the occasions her partner did appear they argued.

Specifically sometime between 6-8pm on 14 August 2010 they argued to the extent there was some physical interaction but it is not clear how much. The deceased was clearly angry with her partner when he eventually left to go to a birthday party at Altone Park.

Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 31.

During the early hours of the following morning the deceased was home alone when relatives of her partner called at the unit to inquire as to the whereabouts of her partner. As those relatives left so the deceased’s partner arrived at his home with others and misconstrued the situation. He clearly believed the deceased had been intending to go out or party without him.

He was heard to argue with the deceased at that stage and the others left the address. There was reported by the neighbours some coming and going during the early hours of 15 August 2010 with there being a commotion audible between the deceased and her partner around about 2:40am.

The deceased was injured during the course of that ongoing altercation and those injuries, on the post mortem evidence, would appear to be those relating to her upper body including her head. It is unclear whether she had also received injuries on the evening of 14 August 2010.

For some reason at 3:21am on 15 August 2010 the deceased’s partner telephoned 000 and required the attendance of the police. The deceased was certainly traumatised because she can be heard moaning in the background of the telephone call to the extent the police officer taking the call enquired as to the background distress. The police officer’s questions concerned the Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 32.

deceased’s partner and he hung up after giving a false name and misleading location information.

The police officer attempted to recall the fixed line service but was unsuccessful in making a connection. For a reason which is unexplained the police officer then did not task a police vehicle to the CLI location as, he agrees, he would have expected.

The deceased and her partner then obviously continued interacting to some extent but on the evidence of the neighbours of the sounds they heard at roughly 3:30am it would seem to have been a continued altercation. Certainly the forensic evidence at the scene does not indicate the activities to which the deceased’s partner confessed, directly before the deceased’s death, were consensual. The post mortem examination indicates the deceased received further injuries in her pelvic and anal area at, or close to, the time of her death. The deceased’s partner claims any sexual activities were consensual but in view of the type of injuries and the altercation heard by the neighbours this is extremely unlikely.

As a result of that altercation it is likely the deceased was in a position in which she was unable to breathe, and was unconscious as a result of the brain injuries suffered earlier. The deceased died during that altercation. When her partner understood she had stopped breathing he Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 33.

sought help for the deceased and was very clear, when the police did arrive, he wanted an ambulance.

He was obviously drug affected and had been for a considerable amount of time. In his record of interview he advised police he had been on a five day methylamphetamine binge.

The deceased’s partner pleaded guilty to causing her death and was sentenced accordingly.

I find death arose by way of Unlawful Homicide.

RECOMMENDATIONS In view of the evidence surrounding the 3:21am telephone call to emergency services I make the following recommendations.

Recommendation No. 1 THE WAPol POLICE COMMUNICATIONS CENTRE INCLUDE

THE VOICE CALL FROM 3.21AM ON 15 AUGUST 2010, AS A PRACTICAL CASE STUDY FOR 000 CALL TAKERS TO USE IN THEIR INITIAL TRAINING TO BECOME 000 CALL TAKERS.

CONSIDERATION SHOULD ALSO BE GIVEN TO USING THE CALL AS A REFRESHER CASE STUDY FOR CALL TAKERS IN CERTAIN CIRCUMSTANCES.

Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 34.

Recommendation No. 2 In furthering the development of computer aided dispatch (CAD), WAPol assess it for its capability to include an automated system of electronic alerts, where information relevant to possible dangers at an address, or posed by a caller, can be automatically fed between the CAD job created by a 000 call taker, and the 000 call taker’s screens, via IMS. Alerts should be linked to the confirmed CLI data (name, address and number) and may include such things as previous domestic violence incidents at the address, or those involving the caller; previous calls from the number to 000 within the last 15-24 hours; violent offences attracting imprisonment (linked to the caller, subscriber, any other names entered into CAD by the call taker). [This system would supplement the current ad hoc reporting of matters of concern by officers external to the PCC]. This should be done with a view to the function being implemented to the extent possible within the core functionality of the future system.

E F Vicker Deputy State Coroner 12 September 2014 Inquest into the death of Shionah Violet Teneille CARTER (F/No 820/2011) page 35.