Deceased
David Davidson Lawson
Demographics
41y, male
Coroner
Coroner King
Date of death
2010-10
Finding date
2016-03-18
Cause of death
unascertained
AI-generated summary
David Davidson Lawson, a 41-year-old Aboriginal man with chronic alcohol use disorder and a history of psychotic symptoms during withdrawal, disappeared from a remote homestead on the Dampier Peninsula in October 2010. He was last seen exhibiting acute psychosis with auditory hallucinations and paranoid delusions about evil spirits and bush men. Despite an extensive multi-agency search, his body was never found. The coroner established death beyond reasonable doubt based on the remote location, harsh environment, his psychological state likely preventing self-care and survival planning, and absence of any contact with services or family afterwards. The cause of death remains unascertained; likely possibilities include dehydration, self-harm related to psychosis, crocodile predation, or drowning. This case highlights the vulnerability of individuals with mental illness and substance use disorders in remote settings, and challenges in managing acute psychiatric crises in isolated communities.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Coroners Act 1996 [Section 26(1)] Western Australia
RREECCOORRDD OOFF IINNVVEESSTTIIGGAATTIIOONN IINNTTOO DDEEAATTHH Ref No: 50/15 I, Barry Paul King, Coroner, having investigated the suspected death of David Davidson Lawson with an inquest held at Perth Coroners Court on 3 December 2015, find that the death has been established beyond all reasonable doubt and that the identity of the deceased person was David Davidson Lawson and that death occurred between 9 October 2010 and 23 October 2010 at an unknown place on the Dampier Peninsula from an unknown cause in the following circumstances: Counsel Appearing : Sgt L Housiaux assisting the Coroner TTaabbllee ooff CCoonntteennttss
CONCLUSION AS TO HOW DEATH OCCURRED AND THE CAUSE OF Inquest into the suspected death of David Davidson Lawson – 589/2011
David Davidson Lawson (the deceased) was a 41 year old Aboriginal man who was last seen at the Jinyaadi Homestead on the Dampier Peninsula. He went missing overnight on Saturday 9 October 2010.
A search was conducted for the deceased, but he was never found.
On 19 May 2011 the Director of Legal Aid in Western Australia, Ted Wilkinson, wrote to the State Coroner on behalf of the deceased’s mother, Patsy Ah Choo, to request an inquest into the deceased’s death
Under section 23 of the Coroners Act 1996, where a person is missing and the State Coroner has reasonable cause to suspect that the person has died and the death was a reportable death, the State Coroner may direct that the suspected death of the person be investigated.
Where the State Coroner has given such a direction, a coroner must hold an inquest into the circumstances of the suspected death of the person and, if the coroner finds that the death of the person has been established beyond all reasonable doubt, into how the death occurred and the cause of death.
In order to be in a position to determine whether he had reasonable cause to suspect that the deceased had died and that the death was a reportable death, on 27 May 2013 former State Coroner Alastair Hope wrote to the Officer in Charge of the Missing Persons Unit of the Western Australia Police requesting information about the deceased’s disappearance.
In early December 2014 the Officer in Charge of the Major Crime Squad forwarded to the State Coroner’s Office a report by Senior Constable Graham Finlayson of the Missing Persons Team in the Major Crime Squad.
The report was dated 4 December 2014.
Inquest into the suspected death of David Davidson Lawson – 589/2011
On 29 December 2014 the present State Coroner directed me to investigate the suspected death of the deceased by holding an inquest.
On 3 December 2015, I held an inquest at the Perth Coroners Court.
The documentary evidence adduced at the inquest comprised Senior Constable Finlayson’s report together with supporting evidence.1 Senior Constable Finlayson attended the inquest to provide oral evidence.2
I have concluded that the death of the deceased has been proved beyond all reasonable doubt, but I have found that the cause of his death is unascertained and that the manner of his death is open.
The following evidence about the deceased’s background was obtained by police from the deceased’s brother Matthew Lawson.3
The deceased was born in Broome and named after his father. His parents separated when he was young but he had a good upbringing. He was educated in Broome and Kewdale, attending high school until year 10.
He developed a lifelong problem with alcohol abuse.
He had a partner, Kitty Roe, with whom he had two children.
Medical records from the Health Department in Broome show that between June 1995 and October 2010 the deceased had about 11 presentations at Broome Hospital, relating mostly to injuries sustained in fights or 1 Exhibit 1 2 ts 4-5 3 Exhibit 1, Tab 2 Inquest into the suspected death of David Davidson Lawson – 589/2011
alleged assaults, alcohol withdrawal symptoms, and chest and skin infections.4
He was linked up to the Kimberley Community Drug Service Team and agreed to rehabilitation. He had wanted to attend Milliya Rumurra but there was a four week waiting period at the time. Milliya Rumurra was a non-government residential treatment and rehabilitation facility in Broome. The rehabilitation program was a minimum of 12 weeks.
On 4 April 2007 the deceased was admitted to Broome Hospital for eight days with alcohol withdrawal symptoms, including early delirium tremens and insomnia. He reported experiencing past seizures related to alcohol usage.
On 11 October 2007 the deceased was admitted for five days with alcohol withdrawal. Two referrals for rehabilitation were arranged.
On 13 December 2007 the deceased was admitted to Broome Hospital with acute psychotic symptoms, including auditory hallucinations of aggressive voices and birds calling his name, after stopping drinking five days previously. He was seen by a locum psychiatrist who prescribed olanzapine and diazepam. He was discharged on 17 December 2007, at which time he said that he no longer heard voices and was determined to ‘stay off grog.’ He said that he planned to go and live at the family bush property.5
The deceased’s last admission was from 2 January 2009 to 8 January 2009. He presented with auditory hallucinations and delirium tremens after stopping drinking two days earlier. He said that he had been dry for 10 months but relapsed at Christmas time. After his symptoms settled with diazepam he was reviewed on several occasions by a community drug service worker to 4 Exhibit 1, Tab 2 5 Exhibit 1, Tab 2 Inquest into the suspected death of David Davidson Lawson – 589/2011
discuss a safety plan. A meeting was held with his brother who said that he would take the deceased out to the bush property where the deceased liked to stay and where he could remain off alcohol.6
While the dates are not clear, it appears that the deceased completed the Milliya Rumurra rehabilitation program in 2008 or 2009.
The deceased’s also self-presented at the Kimberly Mental Health and Drug Service (KMHDS) on 30 March 2009 after stopping binge drinking two days previously.
He was given olanzapine and diazepam. He said that he was planning to leave town to dry out.7
The deceased had a relatively extensive criminal history, including convictions for traffic offences, public nuisance offences and violence offences.8
The deceased was known to have good bush skills, with the ability to live off the land and knowledge of the location of fresh springs around the family’s bush property.9
The deceased’s family’s bush property, which they called ‘the block’ was known as the Jinyaadi Homestead (the homestead). It was located about 180 kms by road northeast of Broome on the eastern side of the Dampier Peninsula on King Sound. As I understand the evidence, the nearest community was Wulununjur Community.10 Offshore from the homestead was Valentine Island.11 6 Exhibit 1, Tab 12 7 Exhibit 1, Tab 2 8 Exhibit 1, Tab 2 9 Exhibit 1, Tab 14 10 Exhibit 1, Tab 9 11 Exhibit 1, Tab 6 Inquest into the suspected death of David Davidson Lawson – 589/2011
The deceased had been staying at the homestead for about 5 years before his disappearance on the night of 9 October 2010. For about a week before that night, his friend Peter Ward had been staying at the homestead with the deceased. Mr Ward, who lived in Broome, would regularly visit the deceased at the homestead and would bring out stores, including food, diesel and general stores.
Mr Ward stated that the deceased had been fine throughout that week, though he told Mr Ward on Thursday 7 October 2010 that he had not slept well the previous night and that he might go into Broome to get medication from the KMHDS that morning.12
The deceased decided not to go to Broome, but Mr Ward did go back. When Mr Ward left the homestead, the deceased appeared to be happy and content. Mr Ward planned to return the next day or Saturday 9 October
Due to problems with his vehicle, he did not return until Sunday 10 October 2010.13
At about 2.00 pm on 9 October 2010 the deceased’s nephew, Rodney Edwards, arrived at the homestead with his children and girlfriend to visit with his uncle.14
Another of the deceased’s nephew’s, Shannon Carlton, arrived at the homestead at about the same time with his partner, Michelle Councillor.15
When the two groups arrived, they noticed that he deceased was acting strangely. He appeared agitated and indicated that he was hearing voices. He said repeatedly that the Featherfoot, an evil spirit, was going to kill them all. He paced around while talking to himself and shouting, presumably at the voices he was hearing. 16 12 Exhibit 1, Tab 15 13 Exhibit 1, Tab 15 14 Exhibit 1, Tab 13 15 Exhibit 1, Tab 14 16 Exhibit 1, Tabs 13 and 14 Inquest into the suspected death of David Davidson Lawson – 589/2011
Mr Edwards and Mr Carlton calmed the deceased down and Mr Carlton gave him a cold beer. The deceased said that he needed to go to the hospital to get his medication. His paranoia appeared to continue as he repeatedly expressed his fear of the Featherfoot. He told his family to sleep in the light.17
At about 8.00 pm the deceased’s family gave him a dinner of beef stew and rice and gave him some water.
The deceased indicated that he would not be able to sleep because, if he did, ‘the two bush men’ would kill him. He began to act on his psychotic delusions, running around the homestead, gesticulating the throwing of spiritual powers at the bush men and calling out to the family to give him the power to kill the bush men. He lit four campfires and used up most of the stock of firewood.18
By about 11.00 pm the deceased had finally calmed down and could not be heard by his nephews and their families.19
The next morning Mr Edwards got up to make a fire and noticed that the deceased was gone. Mr Carlton had slept in the deceased’s car, so it was still at the homestead.20
Mr Edwards and Mr Carlton searched the homestead without success. Mr Carlton and Ms Councillor then drove to another property, calling the deceased’s name and sounding the vehicle’s horn, but they saw no tracks or any other sign of the deceased.21
Mr Carlton noted that the deceased would normally take a dog when he left the homestead, but that this time all the dogs, water, spears and torches remained at the homestead.22 17 Exhibit 1, Tab 14 18 Exhibit 1, Tab 14 19 Exhibit 1, Tabs 13 and 14 20 Exhibit 1, Tab 14 21 Exhibit 1, Tabs 13 and 14 22 Exhibit 1, Tab 14 Inquest into the suspected death of David Davidson Lawson – 589/2011
That morning Mr Carlton sent text messages to other family members to inform them that the deceased was missing. In the afternoon he called family in One Arm Point.23 He and Ms Councillor remained at the block in case the deceased returned.
At about 6.40 pm on Sunday 10 October 2010, another of the deceased’s nephews, Rohan Langtree, called police in Broome to notify them that the deceased was missing.
At about 7.35 pm on 10 October 2010 Sergeant Kazandzis at the Broome Police Station called Sergeant Neville Ripp, who was the Officer in Charge of the Dampier Peninsula Multi-Functional Policing Facility in, as I understand it, Lombadina Djarindjin. Sergeant Ripp made a phone call to the One Arm Point Community chairperson and confirmed that the deceased’s family were concerned about his welfare.24
Sergeant Ripp and Senior Constable Litherland drove to the homestead, arriving at about 1.25 am on 11 October
They spoke to family members, whom I take to be Mr Carlton and Ms Councillor, and then camped for the night.25
At about 6.00 am that morning, Sgt Ripp and Senior Constable Litherland awoke and spoke to the deceased’s family in more detail. Sgt Ripp looked over the cliff to King Sound and saw a fish net laid out across the sand, uncovered at low tide. He walked down to the beach to inspect the net but saw no footprints.
Sergeant Ripp and Senior Constable Litherland searched around the homestead and drove to the Malaburra Community and the Wulununjur Community where they conducted searches. At the Wulununjur Community they spoke to a man who had been there since 7 October 23 Exhibit 1, Tab 14 24 Exhibit 1, Tab 4 25 Exhibit 1, Tab 4 Inquest into the suspected death of David Davidson Lawson – 589/2011
The man had not seen the deceased, though he had seen the deceased’s family searching for him on 10 October 2010. The two police officers searched surrounding bush tracks but saw no sign that the deceased had been there.
That morning Sergeant Kazandzis met with the Fire and Emergency Services Authority (FESA) District Manager in Broome in order to coordinate State Emergency Services (SES) involvement and to consider air support.26
At about 11.00 am two senior Aboriginal police liaison officers with two vehicles carrying the deceased’s family members and volunteer searchers arrived at the homestead. Sergeant Ripp organised the searchers into parties and directed them to search to the south and northwest. He arranged for quad bikes to be brought from the Dampier Peninsula police station.
An aircraft from Derby with two SES observers was expected to arrive at about 10.15 am to conduct aerial searches over land within 10 kms of the block, but there is no evidence to indicate that it arrived.27
The quad bikes arrived early that afternoon, as did more volunteers from One Arm Point. At 3.50 pm the FESA District Manager arrived with six SES volunteers.
For the rest of the afternoon searchers combed the cliff and beach areas until about 5.45 pm, when fatigue and failing light dictated a break in the searches.
At 9.25 pm Sergeant Andrew Henshaw, a qualified land search and rescue officer, arrived to act as search mission controller.
The next morning, 12 October 2010, the Aboriginal police liaison officers and several relatives used motorbikes and quad bikes to search mudflats and a lake near Malaburra Springs to the northeast of the 26 Exhibit 1, Tab 8 27 Exhibit 1, Tab 8 Inquest into the suspected death of David Davidson Lawson – 589/2011
homestead. Several Bardi Rangers attended to take part in the search.
Dr Luckin consulted with a colleague who was a psychiatrist and advised that: a. the reported psychosis and paranoia exhibited by the deceased was common in Aboriginal persons withdrawing from alcohol; b. due to the deceased’s psychosis, he may not think about food or water; c. the deceased may be actively avoiding searchers; d. the deceased’s paranoia may cause him to defend himself against searchers; e. the deceased would require 500-600 millilitres of water per day if immobile and 1 litre per day if mobile, and he may be near a water source; f. the deceased’s time frame for survival with water was at least a week and without water was three days; and g. the best practice was to search for at least two times the time frame for survival.28
For the next three days the ground search continued with the use of motorcycles, quad bikes and searchers on foot. By midday on 13 October 2010 there were 20 Rangers, 20 community members, six police officers, two FESA managers, three Broome SES volunteers and five Derby SES volunteers. A helicopter was used to sweep a 20 km by 10 km area and observers in a fixed wing aircraft were making a grid search offshore.
The search was difficult for a number of reasons, including: 28 Exhibit 1, Tab 8 Inquest into the suspected death of David Davidson Lawson – 589/2011
a. while the search was not complex, the remote location and high temperatures appeared to affect logistical support and searcher fatigue;29 b. the tree canopy was very thick and the bushland was dense, making aerial searching difficult and presumably limiting the use of quad bikes;30 and c. there were salt water crocodiles seen in the area, affecting the safety of the searchers and also raising the possibility that the deceased had been taken by a crocodile.31
I have had the benefit of a statement by Dr Luckin based on his contemporaneous notes of his involvement in providing advice during the search. Dr Luckin considered that, given the deceased’s mental state, it was extremely unlikely that the deceased had found water and was looking after himself. If the deceased had not found water, the practical limit of survival was 12 October 2010.32
Dr Luckin stated that, in the unlikely event that the deceased was still alive, he would have probably been immobile from dehydration, lying under scrubby vegetation and completely unable to help himself or searchers. He would have been extremely difficult to see, so searchers could have walked past him within a few metres and not see him.
Dr Luckin also noted that the deceased may have been actively avoiding searchers, or he may have caused himself harm as a result of his psychosis.33
By the end of 14 October 2010 the search was scaled down to the local police officers and the Ranger groups.
29 Exhibit 1, Tab 9 30 Exhibit 1, Tab 17 31 Exhibit 1, Tab 17 32 Exhibit 1, Tab 16 33 Exhibit 1, Tab 16 Inquest into the suspected death of David Davidson Lawson – 589/2011
Apart from a report on 12 October 2010 of the finding of tracks appearing to be made a couple of days previously, no trace of the deceased was ever found.
The deceased’s car was still at the homestead. To check whether he had caught a lift to Derby, police officers checked known addresses in Derby without success.34
Senior Constable Greatorex of the Missing Persons Team of the Major Crime Squad carried out an investigation commencing in October 2010. Senior Constable Greatorex obtained the following records relating to the deceased: a. medical records; b. Centrelink records; c. Medicare records; d. immigration records; e. financial records; and f. records from WA Police and other government agencies’ databases.35
That investigation established that the deceased had no contact with Broome Hospital, his bank or any of the government agencies after his disappearance. His last contact with Centrelink was on 29 September 2010 and his last transaction apart from automatic transactions was on 5 October 2010. His bank account was closed on 27 December 2013.36
WA Police conducted a number of public awareness strategies in order to elicit information from members of 34 Exhibit 1, Tab 16 35 Exhibit 1, Tab 2 36 Exhibit 1, Tab 2 Inquest into the suspected death of David Davidson Lawson – 589/2011
the public, including television and radio interviews and the provision of information to the West Australian Newspaper.37
37 Exhibit 1, Tab 2 38 Exhibit 1, Tab 2 Inquest into the suspected death of David Davidson Lawson – 589/2011
It is not possible on the evidence to find either how death occurred or the cause of death.
It is perhaps likely that the deceased succumbed to dehydration, but in his psychotic state he may also have caused himself an injury that led to his death. It is also possible that the deceased was taken by a crocodile or that he fell from a cliff and was swept out to sea.
During the search, it was also considered possible that the deceased had swum out to Valentine Island,39 which opens the possibility that the deceased drowned or was taken by a crocodile while attempting to do so.
In these circumstances, I make an open finding as to how death occurred and I find that the cause of death is unascertained.
B P King Coroner 18 March 2016 39 Exhibit 1, Tab 8 Inquest into the suspected death of David Davidson Lawson – 589/2011
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