Inquest into the Death of Thomas Charles WILLIAMS

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

RREECCOORRDD OOFF IINNVVEESSTTIIGGAATTIIOONN IINNTTOO DDEEAATTHH Ref: 38 /15 I, Sarah Helen Linton, Coroner, having investigated the death of Thomas Charles WILLIAMS with an inquest held at the Perth Coroner’s Court, Court 51, CLC Building, 501 Hay Street, Perth on 6 October 2015 find that the identity of the deceased person was Thomas Charles WILLIAMS and that death occurred on 7 August 2012 at the Canning River near Spring Road, Thornlie as a result of immersion (drowning) in the following circumstances: Counsel Appearing: Ms I O’Brien assisting the Coroner.

Mr G Huggins appeared for the Commissioner of Police.

Mr M Trowell QC appeared for the family of the deceased.

TABLE OF CONTENTS INVESTIGATION INTO SIGHTINGS OF DECEASED AFTER 7 AUGUST 2012 AND Inquest into the death of Thomas WILLIAMS (892/2012)

IINNTTRROODDUUCCTTIIOONN

1. On 14 August 2012 the body of Thomas Williams (the deceased) was found submerged in the Canning River, near Spring Road Bridge in Thornlie, by some students who were canoeing in the area.

2. The last time the deceased had been seen alive was one week earlier, on 7 August 2012, when he was seen by police running towards the Spring Road Bridge after they had tried to approach him.

3. Because of the police involvement with the deceased immediately prior to the last time he was seen alive, an inquest was required to investigate whether the death was caused, or contributed to, by any action of a member of the police, pursuant to s 22(1)(b) of the Coroners Act 1996 (WA).

4. Given the week long delay between the deceased’s disappearance and the finding of his body, the deceased’s family had also raised concerns that he may have met with foul play in the intervening week.

5. To explore those issues, I held an inquest at the Perth Coroner’s Court on 6 October 2015.

6. The documentary evidence included a comprehensive report of the death prepared by the Western Australia Police, as well as various other exhibits related to the ongoing coronial investigation.1 A number of witnesses were also called to give oral evidence at the inquest.

TTHHEE DDEECCEEAASSEEDD

7. The deceased was born on 10 October 1974 in Narrogin, Western Australia and grew up with his parents and siblings in the Narrogin and Wagin areas.2

8. As a young adult the deceased began a relationship with Kylie Martin, with whom he had two children. The relationship between the deceased and Ms Martin ended in 1996 when the deceased began a relationship with his new partner, Ms Tracey Hansen.3 The deceased and Ms Hansen began living together, 1 Exhibits 1 – 5.

2 Exhibit 1, Tab 3, 2.

3 Exhibit 1, Tab 3 Inquest into the death of Thomas WILLIAMS (892/2012) 2

with Ms Hansen’s children, in July 1996 while the deceased’s children remained living with Ms Martin.4

9. The deceased and Ms Hansen lived in various locations around the Perth metropolitan area. While living in Beechboro in 1997 Ms Hansen became pregnant with the deceased’s son, but sadly he was later stillborn.

10. Around that time Ms Hansen became aware that the deceased had started to use amphetamines, injecting the drug on almost a daily basis.5 The deceased was not working full-time during this period, although he was doing some casual farm work.6

11. In 2003 the deceased started working more regularly at Swan TAFE, as well as doing steel fabrication in Malaga and steady farm work in Wagin. As a consequence the deceased’s social circumstances improved. He stopped using drugs and gained access to his children through the Family Court.7

12. However, as the work opportunities ended in 2005 the deceased fell back into amphetamine use again.8 Around this time the deceased began to complain of chest pains and shortness of breath. Ms Hansen witnessed some of these events, which she described as serious attacks that resulted in the deceased “lying on his back struggling to breathe.”9 The deceased declined to call an ambulance at these times, or seek any form of medical treatment, but chose to purchase asthma inhalers from the chemist, which he would keep “within arms reach”10 and use when he had shortness of breath.

13. The deceased would most commonly experience these attacks immediately after he had injected amphetamine, and they would last approximately 15 minutes, or until he had used an asthma inhaler.11 He would experience a serious attack once every couple of weeks.12 The deceased had also informed police that he was asthmatic and used Ventolin to control it.13

14. The deceased’s illicit drug habit eventually led to him committing criminal offences and serving time in prison.14 In 2008, after being released from prison, the deceased and Ms Hansen moved 4 Exhibit 1, Tab 6 [8].

5 Exhibit 1, Tab 6 [11] – [15].

6 Exhibit 1, Tab 6 [21].

7 Exhibit 1, Tab 6 [23] – [25].

8 Exhibit 1, Tab 6 [26].

9 Exhibit 1, Tab 6 [30].

10 Exhibit 1, Tab 6 [28] – [31].

11 Exhibit 1, Tab 6 [33].

12 Exhibit 1, Tab 6 [34].

13 T 39 – 40; Exhibit 1, Tab 3, 5; Exhibit 3.

14 Exhibit 1, Tab 6 and Tab 22.

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to Bunbury. After a brief period of abstinence, the deceased lapsed back into drug use. They left Bunbury in 2009 and moved back to Perth to live with Ms Hansen’s daughter in Leederville.15

15. After returning to Perth Ms Hansen worked away regularly on the mines and the deceased remained in Perth. He was not working and still using amphetamines. The couple began fighting regularly and Ms Hansen found out that the deceased was having an affair. The deceased and Ms Hansen then separated.16

16. Around the time they separated Ms Hansen’s daughter took out a violence restraining order against the deceased and the deceased later returned to prison to serve another sentence for various offences. This occurred in late 2010 and early 2011.17 Ms Hansen stopped having contact with the deceased around this time although they remained friends.18

17. The deceased appears to have then spent time living with his sister in Bentley and with his family in Wagin thereafter.19

18. On 18 May 2012 the deceased was charged with the offences of stealing a motor vehicle and breaching a violence restraining order and released on bail. He failed to attend the Narrogin Magistrates Court on 5 June 2012 in relation to those charges and a warrant was issued for his arrest.20 The WA Police also issued a notice for a look out to be kept for the deceased for suspicion in relation to other offences. The notice indicated that the deceased was believed to be residing in Wagin and was known to be actively avoiding apprehension.21

19. Even when confronted by the police the deceased was known to try to run away and would never willingly give himself up.

Ms Hansen stated that in the 15 years she was with the deceased he would run, jump fences and even swim across rivers to escape the police. When he ran he would dump any heavy items to make himself lighter to improve his chances of escape. Ms Hansen said the deceased would then “run until he had nothing left and couldn’t run anymore.”22 Consistent with Ms Hansen’s account is a hospital report included in the brief of evidence that records the deceased receiving medical treatment on 10 October 2011 for a 15 Exhibit 1, Tab 6 [38] – [41].

16 Exhibit 1, Tab 6 [42] – [47].

17 Exhibit 1, Tab 22.

18 Exhibit 1, Tab 6 [46] – [48].

19 Exhibit 1, Tab 8 [9].

20 T 3.

21 T 41; Exhibit 1, Tab 3 and Tab 22.

22 Exhibit 1, Tab 6 [49] – [52].

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cut to his right foot sustained whilst he was running away from police through the bush.23

EEVVEENNTTSS IINN JJUULLYY AANNDD EEAARRLLYY AAUUGGUUSSTT 22001122

20. In July 2012 the deceased approached a friend, William Rowe, and told him that he had nowhere to live. Mr Rowe knew that the deceased was a daily heavy user of speed. Indeed, the deceased once described speed to Mr Rowe as “my true love.”24 Because he was a friend, Mr Rowe told the deceased he could come and stay at Mr Rowe’s house for a couple of weeks but on the provison that he wasn’t allowed to inject drugs in the house, as Mr Rowe did not want his 12 year old son exposed to that kind of behaviour.25

21. When the deceased moved in to Mr Rowe’s house he had festering boils on his stomach and one of his arms. Mr Rowe offered to take the deceased to see a doctor but he refused. Mr Rowe was sufficiently concerned about the boils to speak to the deceased’s sisters about them, however the deceased told them to mind their own business. Apart from the boils the deceased otherwise appeared fit and well.26

22. The deceased did not always stay at Mr Rowe’s house over this period and when he did he was not allowed to have friends visit due to concerns about Mr Rowe’s son. However, Mr Rowe was aware that the deceased was having problems with a man called Bilyal who lived in the suburb of Parkwood. The argument was apparently over money owed for drugs, and both the deceased and Bilyal claimed the other owed them money. As far as Mr Rowe was aware, the dispute was only verbal and had not led to a physical fight between them.27

23. Around 31 July 2012 a detective attended Mr Rowe’s house looking for the deceased. Mr Rowe was informed that police were actively looking for the deceased and he had an outstanding warrant.28

24. On Saturday, 4 August 2012 the deceased spent the night at Mr Rowe’s home. Mr Rowe explained to the deceased that, given the police were looking for him, the deceased would have to move out as Mr Rowe had responsibilities to his young son. The 23 Exhibit 1, Tab 20.

24 Exhibit 1, Tab 8 [15] – [20].

25 Exhibit 1, Tab 8 [21] – [23].

26 Exhibit 1, Tab 8 [25] – [30].

27 Exhibit 1, Tab 8 [31] – [35].

28 Exhibit 1, Tab 8 [36] – [37].

Inquest into the death of Thomas WILLIAMS (892/2012) 5

deceased apparently accepted Mr Rowe’s decision and indicated there was no ill-will between them.29

25. The following day the deceased left the house at about 5.00 or 6.00 pm with an acquaintance, Drew Taylor, who had met the deceased through Mr Rowe. Mr Taylor drove the deceased to a house and the deceased purchased amphetamine, which he later shared with Mr Taylor.30

26. The deceased and Mr Taylor returned to Mr Rowe’s house about 9.30 pm that evening and they left the house again at about 10.30 pm. At the time the deceased left the house on 5 August 2012 he was wearing black jeans, white runners and a black hooded zip-up jumper. Mr Rowe stated that the deceased would often wear the same outfit for a few days as he didn’t have a lot of clothing.31

27. About an hour after they had left Mr Rowe realised that his mobile telephone was missing. He tried ringing his mobile telephone but no one answered. He then rang Mr Taylor, who admitted that the deceased had Mr Rowe’s phone. Mr Taylor indicated he thought they should return the phone to Mr Rowe but Mr Rowe overheard the deceased say “I’m in the shit now may as well get a bit more on me.”32 Mr Rowe was very angry about the deceased taking his phone and rang the phone repeatedly but the calls were never answered.33

28. While the deceased and Mr Taylor were together the deceased was also heard to have a telephone conversation with the person called Bilyal. Mr Taylor could hear Bilyal screaming that he wanted to kill the deceased. The deceased didn’t seem concerned by the threats and said that he wanted to meet up with Bilyal.

The deceased and Mr Taylor then went to the Caltex service station on Williams Street and waiting for Bilyal, but he didn’t show up and they eventually left.34

29. Mr Taylor and the deceased went to a friend’s house that night where they smoked some of the amphetamine and listened to music. The deceased was in a good mood while they were there.

Mr Taylor left the deceased at the house at about 2.00 am on Monday, 6 August 2012.35 The deceased told Mr Taylor he would 29 Exhibit 1, Tab 8 [40].

30 Exhibit 1, Tab 7.

31 Exhibit 1, Tab 8 [44] – [45].

32 Exhibit 1, Tab 8 [51].

33 Exhibit 1, Tab 8 [52].

34 Exhibit 1, Tab 7 [25] – [33].

35 Exhibit 1, Tab 7 [21] – [23].

Inquest into the death of Thomas WILLIAMS (892/2012) 6

call him later, but Mr Taylor doesn’t think that he did hear from the deceased again.36

30. Mr Rowe also did not hear again from the deceased, which he noted was unusual as he would normally speak to him daily.

However, given the circumstances of their last parting and the theft of Mr Rowe’s telephone, it is perhaps not surprising that the deceased did not contact Mr Rowe again.37

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31. On Tuesday, 7 August 2012 the deceased telephoned his former partner, Ms Hansen. The call was made on Mr Rowe’s mobile phone. Ms Hansen answered the call and spoke to the deceased.

He asked her if she wanted some amphetamine and she agreed.

They arranged that she would catch a train and go to Thornlie to get it.38 During the train journey to Thornlie Ms Hansen spoke to the deceased several times on her mobile phone. She arrived at Thornlie train station not long after midday.39

32. When Ms Hansen arrived at the train station she saw the deceased standing in a park nearby. She recalls he was wearing jeans, a black t-shirt with writing on it, white sneakers and a green jacket/overcoat.40 They spoke briefly and the deceased then left Ms Hansen alone for a period. She became annoyed and went back to the train station and boarded a train intending to return home. However, the deceased then called her and asked her to come back so she got off the train and met him again.41

33. They then walked along the train line towards the river. While they were walking Ms Hansen asked the deceased for some amphetamine. He showed Ms Hansen several plastic bags with varying amounts of amphetamine in them. He told her the quality was very good and then gave Ms Hansen approximately 2 points, with the intention they would share it and have 1 point each.42

34. At approximately 2.20 pm the deceased and Ms Hansen began walking down a residential street. As they walked along the street the deceased and Ms Hansen were observed by some of the residents. Ms Hansen walked into the front yard of one house and used a tap to get some water to mix with the amphetamine.

After they mixed the amphetamine and water the deceased 36 Exhibit 1, Tab 7 [24].

37 Exhibit 1, Tab 8 [62].

38 Exhibit 1, Tab 6 [54] – [59].

39 Exhibit 1, Tab 6 [62] – [64].

40 Exhibit 1, Tab 6 [65] – [66].

41 Exhibit 1, Tab 6 [67] – [69].

42 Exhibit 1, Tab 6 [70] – [73], [75].

Inquest into the death of Thomas WILLIAMS (892/2012) 7

suggested they walk away from the area to get away from the people watching them.

35. They walked a short distance away and Ms Hansen injected her point of amphetamine. At this time the deceased had the bag containing the remaining point of amphetamine mixed with water in his hand.43 The deceased was intending to use the amphetamine when they were down by the bridge on Spring Road so they walked along the river’s edge towards the bridge. The deceased was walking about 3 to 4 metres ahead of Ms Hansen.

Before they reached the bridge Ms Hansen saw the deceased drop his jacket and start running towards the bridge and the river. As he started running he called out “See they called the police on us.”44 Ms Hansen then turned and saw two policemen in uniform running towards them.

36. The deceased was correct that a resident had reported their activities to the police. The resident had spoken to the deceased and Ms Hansen and had thought their behaviour had seemed suspicious, prompting her report.45 Two police officers, Constable Shaun Gilbert and First Class Constable Nigel Andrews were on duty at the time conducting patrols of the area in a marked police vehicle. At 2.32 pm they were patrolling in Thornlie when they were tasked to attend the vicinity of O’Dell Street in Thornlie.

They were told that a report had been received of a male Aboriginal person and female Aboriginal person possibly ‘casing’ houses in that street. The police officers went and spoke to the resident who had made the report and obtained a description of the two persons of interest. The resident indicated they had last been seen walking in an easterly direction towards Spring Road, which is a short distance from O’Dell Street.46

37. The two police officers then drove in their police vehicle slowly along the footpath area that runs alongside Canning River and has a path that leads up to Spring Road. They saw a man walking his dogs and asked him if he had seen two people matching the resident’s description. The man informed the police he had seen them not long before so the police continued to drive along the path towards Spring Road. When they were within 250 metres of Spring Road they saw the deceased and Ms Hansen, who matched the description of the two people given by the resident.47 Constable Gilbert recalled the deceased was 43 Exhibit 1, Tab 6 [74] – [80].

44 Exhibit 1, Tab 6 [80] – [85].

45 Exhibit 1, Tab 9.

46 Exhibit 1, Tab 10 [2] – [5].

47 Exhibit 1, Tab 10 [7] – [12].

Inquest into the death of Thomas WILLIAMS (892/2012) 8

wearing black pants, a black shirt and a trench coat at that time.48

38. First Class Constable Andrews stopped the vehicle and the officers got out and moved towards the deceased and Ms Hansen.

As they approached them Ms Hansen stood still but the deceased dropped his trench coat and began running towards the Spring Road overpass. Constable Gilbert yelled out, “Police, Stop!” and then began to run after the deceased.49 As he ran Constable Gilbert made a broadcast over the secure police radio advising of the situation and requesting any available resources to assist.

39. Constable Gilbert continued to run after the deceased for a short time but as the deceased ran towards the bridge he ran over a small hill and Constable Gilbert lost sight of him. Constable Gilbert ran under the Spring Road overpass and came out to the other side but he still couldn’t see the deceased. As there is a large open space area on that side he was quite sure that the deceased had not run past the bridge area. Constable Gilbert ran back to higher ground and saw a marked Public Transport Authority security vehicle pull over so he spoke to them and gave them a description of the deceased, which they broadcast over their radio network.50 Constable Gilbert then continued to look for the deceased as he headed back to his partner.51

40. In the meantime, First Class Constable Andrews had been speaking to Ms Hansen, whom he knew from previous dealings.52 Constable Gilbert returned while they were talking. Ms Hansen had noted that the deceased was a long way ahead of Constable Gilbert when the chase began and noted that Constable Gilbert had only appeared to chase the deceased for a short time. When Constable Gilbert returned she told the two police officers the deceased’s identity and that he was running because he had a warrant out for his arrest.53 According to Constable Gilbert Ms Hansen also told the police officers that the deceased was desperate to get away and that he had probably jumped into the river, although Senior Constable Andrews did not recall this being said.54

41. The police officers then made inquiries and found out the details of the outstanding warrant for the deceased’s arrest and the multiple warnings listed against him. They were joined by other 48 Exhibit 1, Tab 10 [14].

49 Exhibit 1, Tab 10 [16] – [20].

50 T 101; Exhibit 1, Tab 10 [24] – [28].

51 Exhibit 1, Tab 10 [30].

52 T 111.

53 Exhibit 1, Tab 6 [89] – [94].

54 T 111; Exhibit 1, Tab 6 [93] and Tab 10 [31] – [33].

Inquest into the death of Thomas WILLIAMS (892/2012) 9

police officers and continued searching throughout the bush area and alongside the river but could not locate the deceased.55

42. Police intelligence identified that the deceased had associations with the occupants of 12 Spring Road, Thornlie, which was nearby. Police officers conducted a search under section 132(2)(a) of the Criminal Investigation Act 2006 (WA) at the house but the deceased was not there.56

43. Constable Gilbert and Senior Constable Andrews had a further look along the western bank of the river and surrounding park area as they returned to their vehicle but there was no further sign of the deceased.57 They only searched the side of the river where their vehicle was parked, and did not search the other side of the river where the deceased’s body was eventually found.58

44. When First Class Constable Andrews had stopped Ms Hansen she was carrying the jacket the deceased had dropped. She gave him permission to search the jacket. Inside the jacket he found a mobile phone and an uncapped syringe. First Class Constable Andrews returned both items to Ms Hansen and she was eventually told that she was free to leave.59 Ms Hansen headed towards the Maddington shopping centre to wait for the deceased to call her as she knew the deceased would not go back to the river if the police were there. She thought he might meet her at the shops instead. While at the shops she received a telephone call from Mr Rowe’s daughter who said that Mr Rowe wanted his mobile phone back, which seems to have been the one in the deceased’s jacket. They made arrangements for Ms Hansen to meet Mr Rowe at the shopping centre that night so that the phone could be returned.60

45. When Ms Hansen returned home after meeting Mr Rowe that afternoon, she spoke to her daughter, Narisa, who told her that the deceased had rung Ms Hansen’s home number and spoken to Narisa a couple of times. Police enquiries confirmed that data from the deceased’s mobile telephone showed the deceased had made calls to Ms Hansen’s home number at 1.59 pm (228 seconds) and at 2.06 pm (504 seconds). Both the calls were prior to the deceased last being seen by Ms Hansen and the police.61 Ms Hansen did not hear from the deceased for the rest of the week.62 55 Exhibit 1, Tab 10 [34] – [35].

56 Exhibit 1, Tab 10 [36] – [39].

57 Exhibit 1, Tab 10 [40].

58 T 106.

59 Exhibit 1, Tab 11.

60 Exhibit 1, Tab 6 [97] – [103].

61 T 25; Exhibit 1, Tab 2.

62 Exhibit 1, Tab 6 [118].

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DDIISSCCOOVVEERRYY OOFF TTHHEE DDEECCEEAASSEEDD’’SS BBOODDYY

46. On Tuesday, 14 August 2012 a group of high school students met at 7.30 am for an outdoor education class. The plan was to go canoeing along the Canning River. They were driven by their teacher in the school bus to a carpark on Spring Road next to the Canning River in Thornlie. They got into the water at approximately 8.15 am. They entered the river with their canoes about 10 metres south east from the bridge and began to paddle upstream towards the bank on the eastern side of the river.

47. Not long after they had begun paddling one of the students noticed a head visible above the water in the reeds close to the bank on the eastern side of the river. Because the water was muddy it was not possible to see anything below the head on the surface. The student told the teacher what they had seen and the teacher came over and checked to ensure that the person was not alive before directing all of the students back out of the water.

The teacher then telephoned the police and made a report. Police attended shortly afterwards and were directed by the teacher to where the head was visible from the riverbank.63 The body was eventually identified as that of the deceased and it became known that the deceased had last been seen in that area being pursued by police one week earlier.

Exhibit 1, Tab 23 63 Exhibit 1, Tabs 13 and 14.

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48. A team from the WA Police Forensic Division attended the scene.

They noted that the area where the deceased was located is a hundred metres east of the Canning River Bridge. The area of the river is approximately 8 to 10 metres wide and the river was flowing reasonably and was brown with sediment on that day.

The banks down river and up river of the deceased were searched for any signs of disturbance to indicate areas where people may have walked, carrying or dragging a person to the river’s edge. A few small minor areas of grass disturbance were observed but the soil in the area showed no visible disruption. In the area east of the body four cigarette butts were collected but it was noted that near the butts was a path that was well used by the public so there was nothing unusual about cigarette butts being found there.64 The cigarette butts were not DNA tested.

49. Water police attended and police divers examined the area around the deceased and observed no weights or tie downs. They then recovered the deceased’s body from the water. His body was briefly examined and it was noted he was wearing a black AC/DC t-shirt, black jeans and white Puma shoes (which matched the description of the deceased’s clothing he was wearing when last seen by Ms Hansen and the two police officers).65 There was a layer of silt over most exposed areas of skin. There were signs on the skin consistent with prolonged immersion in water. He had visible tattoos and no obvious injuries other than possibly a slight graze to his left eyebrow. In the deceased’s left hand was clutched a small plastic bag, which contained silt and water.

Located in his jeans pockets were another clip seal bag, a set of headphones and a piece of green wire.66 Senior Constable Sims confirmed that the two plastic bags were what are commonly referred to as “deal bags.”67

50. Forensic officers performed a test including a dummy and a diver to see if the passage of a human body was possible through trees and debris in the water into the cut out where the deceased was found. Both the dummy and the diver passed through obstacles but did not go into the little cut out.68 The results of the test supported the conclusion that the deceased’s body had not floated into the area where it was found, but would have required a person to swim into the area if they approached it while in the river.69 64 Exhibit 1, Tab 27.

65 T 39.

66 Exhibit 1, Tab 27.

67 T 43 – 44.

68 Exhibit 1, Tab 27.

69 T 38, 61.

Inquest into the death of Thomas WILLIAMS (892/2012) 12

CCAAUUSSEE OOFF DDEEAATTHH

51. A post mortem examination of the deceased’s body was conducted by a Forensic Pathologist, Dr G.A. Cadden, on 17 August 2012. The body surfaces showed changes in keeping with having been in water and the lungs appeared fluid laden.

The deceased’s clothing and body surfaces showed a silt-like distribution, in keeping with river sediment. There were obvious signs of decomposition change in parts of the face and head and visible signs of the effect of immersion on the hand and feet surfaces.70

52. No preceding pathology of significance was identified, meaning there was no disease that would readily account for the death.

Any signs of asthma would not necessarily have been seen due to the fluid-laden lungs, so the post mortem findings could not assist in that regard.71

53. No injury of significance with respect to the cause of death, that could be confirmed as having occurred in life, was identified. A dental assessment was also carried out with no signs of recent oral trauma identified.72

54. The deceased’s father, Mr Charles Williams, raised specific concerns about a possible bruise he saw on the deceased’s left cheek bone when he did a viewing at the mortuary approximately one week after his body had been found.73 Dr Cadden explained at the inquest that, while he could readily understand why Mr Williams might have thought he had seen a bruise, the prominent colour changes that Mr Williams had seen were actually because of decomposition.74

55. The decomposition was also the likely reason for the deceased having come to the surface with his face above the water as other post mortem findings indicated the deceased had previously been submerged in the water, face down.75

56. Toxicology analysis results showed methylamphetamine and amphetamine in the deceased’s blood and urine. The methylamphetamine was in the range for ‘recreational’ use of methylamphetamine.76 70 T 66 – 68; Exhibit 1, Tab 17, 26.

71 T 69.

72 T 68 - 69; Exhibit 1, Tab 17, 26.

73 Exhibit 2.

74 T 69.

75 T 88.

76 Exhibit 1, Tabs 17 and 18.

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57. From the perspective of trying to identify a cause of death, the most significant of the post mortem findings was the finding of heavy fluid-laden lungs (considered in the context of the deceased being found in a river). Dr Cadden explained that it is a nonspecific finding but it is a finding commonly encountered in a situation where someone has died in an immersion situation.

Another term for “immersion” is “drowning”.77 Dr Cadden agreed in questioning that drowning can be a very rapid event.78

58. At the conclusion of all investigations Dr Cadden finalised the cause of death as unascertained (consistent with immersion in a man with methylamphetamine effect). He noted that immersion (drowning) is a diagnosis of exclusion and the role of methylamphetamine in the death is open to speculation.79 In essence, Dr Cadden’s position was that he could not determine exactly how the deceased died but using a process of excluding other obvious causes of death such as natural disease and injury, and taking into account the circumstances of where the deceased was found and his fluid-laden lungs, a reasonable explanation for the death was immersion and there were no other readily acceptable alternative explanations.80

59. Dr Cadden also explained that the information that the deceased was found with a plastic bag in his hand was a phenomenon that has been observed in immersion situations (although not exclusively in cases of immersion) and is known as cadaveric spasm. It is the almost instantaneous onset of the muscles in the hand grasping something at the time of death.81 Dr Cadden noted, however, that it is a rare forensic phenomenon so there is little literature on it.82

60. As to the possible role played by methylamphetamine, which was present in the deceased’s system at the time of death, Dr Cadden observed that amphetamine can potentially increase body temperature. If the deceased was exerting himself by running and already experiencing an elevated body temperature because of the effect of the methylamphetamine, Dr Cadden considered it possible the deceased might want to get into the water to cool down as he would feel unwell and uncomfortable.83 Methylamphetamine can also cause people to feel confused and affect their judgment, increasing their willingness to take risks such as entering the water in winter. It can also make them

77 T 71.

78 T 76.

79 Exhibit 1, Tab 17.

80 T 75 – 78, 90.

81 T 84 – 85.

82 T 85 - 86.

83 T 82, 90 – 91.

Inquest into the death of Thomas WILLIAMS (892/2012) 14

paranoid and potentially very fearful of being apprehended.84 Dr Cadden explained that these are all “well recognised effects”85 of methylamphetamine.

61. As the methylamphetamine may have had a potential relevance to explaining how the deceased ended up in the location where he was found, Dr Cadden included reference to it as part of his conclusion.

62. Dr Cadden also noted that water is a dangerous environment to become unwell in, so if he became respiratorily challenged in the water, as described by Ms Hansen on occasions when the deceased had taken methylamphetamine in the past, it could have incapacitated his ability to care for himself in the water.86 As Dr Cadden acknowledged, it is well recognised that even people who are good swimmers sometimes still drown because of unexpected events while in water, such as an acute health event or becoming entangled or unconscious.87

63. However, all of these scenarios are speculative without further information as to what happened to the deceased while in the river.

64. Dr Cadden was asked during the police investigation and at the inquest whether he could estimate the post mortem interval from the information available to him. Dr Cadden explained that estimating post mortem interval is far from an exact science and he is unable to determine what duration of time the deceased was in the water prior to being discovered. However, having considered the available evidence and discussing that information with his pathologist colleagues, Dr Cadden indicated that he could not exclude that the deceased’s body had been in the water since 7 August 2012. Although Dr Cadden would have expected the deceased to be more decomposed if that were the case, it was not an absolute factor against a week long PM interval.88 Factors such as the cold temperature of the water (15 degrees), the fact that the river was flowing and the fact it was winter (and hence cold) would all slow the rate of decomposition and possibly provide an explanation for why decomposition was less than might ordinarily be expected if the deceased had been in the water for a week.89 However, of relevance to the evidence of Mr Harrington referred to below is the evidence of Dr Cadden that

84 T 91 – 92.

85 T 92.

86 T 92 – 93.

87 T 93.

88 T 71 – 73; Exhibit 4.

89 T 73.

Inquest into the death of Thomas WILLIAMS (892/2012) 15

in his expert opinion the likely post mortem interval was days, not hours.90

65. Sometime after the post mortem was completed, the deceased’s parents provided his medical records from Narrogin Hospital to the Coroners Court to provide further information about his medical history, including a reported bout of rheumatic fever. The records were reviewed by Professor Bernard Pearn-Rowe, a highly qualified general practitioner and academic at the University of Notre Dame, School of Medicine. Professor Pearn-Rowe concluded that there was nothing in the medical records provided that had any bearing on the cause of death of the deceased. In particular, Professor Pearn-Rowe noted that if there had been any ongoing effect on the deceased’s health from rheumatic fever, in the sense of having developed rheumatic heart disease with damaged heart valves, it would have been apparent during the post mortem examination. However, Dr Cadden found no evidence of heart valve disease.91

66. In conclusion, weighing up all the evidence before me, I am satisfied that deceased died as a result of immersion (drowning).

The reason why he drowned is unknown. The methylamphetamine in the deceased’s system may have played a part in causing the deceased to come into difficulties in the river.

The same can be said for the possibility of an asthma attack.

However, there is insufficient evidence before me to be satisfied that that was the case.

IINNVVEESSTTIIGGAATTIIOONN IINNTTOO SSIIGGHHTTIINNGGSS OOFF DDEECCEEAASSEEDD AAFFTTEERR 77 AAUUGGUUSSTT 22001122 AANNDD RRUUMMOOUURRSS OOFF FFOOUULL PPLLAAYY

67. The deceased’s death was initially investigated by the Major Crime Squad to determine whether there were any suspicious circumstances surrounding the death. After an initial investigation, and particularly taking into account the results of the post mortem examination, it was determined by officers from the Major Crime Squad that the death was not suspicious. The conduct of the investigation was then transferred to Senior Constable Sims who was attached to the Coronial Investigation Unit and had been assisting the Major Crime Squad with the initial investigation.92

90 T 87, 88.

91 Exhibit 1, Tabs 17 and 25 92 T 37; Exhibit 1, Tab 2.

Inquest into the death of Thomas WILLIAMS (892/2012) 16

Report of contact with deceased by ‘Smokey’

68. When Ms Hansen had not heard from the deceased by Monday 13 August 2012 she called a friend of the deceased, who she knew as ‘Smokey’ (real name Colin Harrington) to ask him if he had seen the deceased. Smokey told her that the deceased had come to his house the morning before at about 11.00 am but he had not let the deceased inside the house as he had been feeling sick. Ms Hansen thought this report was strange as the deceased was a night person who would not usually be up and about that early unless he was on amphetamine. She did not consider Smokey to be reliable so she discounted this report but asked Smokey to call her if he heard from the deceased again. She did not hear from the deceased or Smokey after that date.93

69. Smokey was spoken to by police and he signed a statement on 15 August 2012. He indicated that he had known the deceased, whom he knew as ‘Tommie’ (which was the nickname often used by the deceased), for about five years. He did not see him regularly but the deceased would drop in to see Smokey at his house when he was in the area, which was usually about once or twice a month. The deceased would often have a shower and get changed at Smokey’s house, as he kept a bag of clothes there, or he would have a sleep on the lounge.

70. Smokey saw the deceased about four times in the couple of months before the deceased’s death. Most significantly, Smokey told police that he believed he spoke to the deceased on either Sunday 12 August 2012 or Monday, 13 August 2012 (so in the day or two before the deceased’s body was found in the river). He indicated in his statement that he heard a knock on his door at about 11.00 am in the morning and a person he believed to be the deceased identified himself as “Tom” and called him “Uncle”, which is the name the deceased called Smokey. They spoke through Smokey’s bedroom window as Smokey was hungover and had been sleeping so he didn’t want to get out of bed to answer the front door. Smokey recalled that “Tommie” was in good spirits and asked for Debbie Jaeger’s phone number (a lady who lived in the same street as Smokey) and stated that he was looking for drugs. Smokey told him to go to Debbie Jaeger’s house and “Tommie” left. Importantly, Smokey did not actually see the person he thought was the deceased, but only spoke to him through the window.94

71. Smokey, who I will refer to as Mr Harrington from now on, gave oral evidence at the inquest to clarify parts of the statement he 93 Exhibit 1, Tab 6 [119] – [125].

94 T 7; Exhibit 1, Tab 12.

Inquest into the death of Thomas WILLIAMS (892/2012) 17

gave to police immediately after the deceased’s body was found.

He explained that at the time he spoke to police he honestly believed that he had spoken to the deceased that morning.

However, after giving the statement he spoke to Tracey Hansen and found out that the deceased had been found in the river on 14 August 2012 and it seemed likely that he was already dead on the Sunday or Monday morning when Mr Harrington thought he was visited by the deceased.95

72. Mr Harrington explained at the inquest that he knows another person called Tommy (Tommy Quartermaine) who also calls Mr Harrington Uncle Smokey, and he now believes it is possible this was the person who visited him that morning, rather than the deceased.96 Mr Harrington also noted that Tommy Quartermaine was a similar person to the deceased, in the sense of being the kind of person who might be looking for drugs.97 Mr Harrington accepted in questioning that he had been almost positive that he had spoken to the deceased that morning and the only reason he now doubted whether it was the deceased is because of information provided to him that suggested the deceased had already died by that time. However, it is apparent that he has given the matter some thought and is willing to concede that it is possible he was mistaken that morning as to the identity of his visitor.98

73. The investigating officer, Senior Constable Sims, had also spoken to Mr Harrington a few days after he provided his statement to police, and had formed the view that Mr Harrington’s account of having spoken to the deceased a day or two before he was found was not reliable. Senior Constable Sims explained at the inquest that some his reasons for forming this view included the fact that Mr Harrington had not actually seen the person, the evidence of where the deceased was found, the post mortem evidence, and Senior Constable Sim’s own assessment of Mr Harrington as a person who was easily confused.99

74. Having heard Mr Harrington’s evidence that he is now no longer certain that he spoke to the deceased that day, and taking into account the other evidence before me (in particular the decomposition of the deceased’s body indicating he had been dead at least a few days before he was found)100 I am satisfied that Mr Harrington was mistaken when he told police he spoke

95 T 7.

96 T 8 – 9, 17 - 18.

97 T 15 - 16.

98 T 17 – 19.

99 T 47 – 49.

100 T 124.

Inquest into the death of Thomas WILLIAMS (892/2012) 18

with the deceased on either the Sunday or Monday immediately preceding the Tuesday when the deceased was found.

Enquiries regarding Bilyal

75. Senior Constable Sims took the statement from Mr Taylor that referred to the deceased’s argument with the person known possibly as “Bilyal.” He drew the information to the attention of the senior investigation officer of the Major Crime Squad Detective Senior Sergeant Weston.101 Further inquiries were then conducted by Senior Constable Sim and members of the Major Crime Squad to explore whether the person referred to as Bilyal may have had any involvement in the deceased’s death.102

76. Senior Constable Sims detailed at the inquest the steps that were taken to try to locate the telephone number of Bilyal from telephone CCR records and attempts were also made to locate the home of Bilyal in Parkwood. Senior Constable Sims did find a location in Parkwood that had been associated with a Portuguese person known as Bilyal but the house was vacant and enquiries with the neighbours established that the occupants of the house had been gone for a few weeks.103

77. Enquiries with officers from the Drug Squad did not produce any information and no information was able to be provided by the local intelligence analyst posted at Cannington Police Station.

The Major Crime intelligence analysts also could not provide further intelligence to assist in locating Bilyal.104

78. Mr Trowell QC, on behalf of the deceased’s family, was critical of the failure of the police to do more to locate Bilyal. If there had been any evidence to support the conclusion that the deceased had been physically injured prior to, or at the time of, his death or evidence that other people were involved in his death, I would accept that criticism. However, given the post mortem examination strongly suggested that the deceased had not met with foul play, I consider the police investigators pursued that line of enquiry to a sufficient degree.

Family Concerns

79. In January 2014 the deceased’s father, Mr Williams, contacted the Coroner’s Office with further concerns that there may have been foul play involved in the deceased’s death and that he believed he had new information in that regard. This information

101 T 53, 59.

102 T 56.

103 T 56.

104 T 56 – 57.

Inquest into the death of Thomas WILLIAMS (892/2012) 19

was referred first to the solicitors who acted on behalf of the deceased’s family, so that they were aware of the general substance of the allegations, and then referred to the Superintendent of the WA Police Internal Affairs Unit (IAU) for investigation.

80. The concerns raised by Mr Williams were allocated to Detective Sergeant Bell for investigation. Det Sgt Bell met with Mr Williams and another person by the name of Christopher Jones, who was the source of Mr Williams’ new information, to discuss the matter. Mr Jones advised that he had been told that the deceased had been murdered and a serving police officer (not First Class Constable Andrews or Constable Gilbert) may have been involved in the murder together with outlaw motorcycle gang members.

Similar allegations had apparently also been investigated by IAU members previously but Det Sgt Bell pursued his own investigation following the new report. The sources of this rumour were interviewed by Det Sgt Bell and it was found that there was no evidentiary support for the proposition that the deceased was murdered nor that a serving police officer was involved in such an offence related to the deceased’s death.105 Det Sgt Bell met with Mr Williams and his wife in Wagin on 10 April 2014 and provided them with a briefing of the results of his investigation, as well as a general overview of the coronial brief and the lack of suspicious circumstances surrounding their son’s death.106

81. I also note that the family of the deceased were keen for Ms Hansen to be called as a witness at the inquest, as there was a suggestion from them that she knew more relevant information than she had included in her statement to police and had possibly “set up” the deceased. There does not appear to be any evidentiary basis for this allegation. Despite efforts by the Coroners Court staff and police to serve a witness summons on Ms Hansen, she was not able to be located and information was provided that she had a warrant out for her arrest. Although it is regrettable that she could not be served I do not consider that there is any cogent evidence to cast doubt over the account of events given by Ms Hansen to police, which was signed by her as a true and accurate account on 15 August 2012.107 I also note that no submission to the contrary was made to me by counsel at the conclusion of the hearing.

105 Exhibit 1, Tab 5.

106 Exhibit 1, Tab 5.

107 Exhibit 1, Tab 6.

Inquest into the death of Thomas WILLIAMS (892/2012) 20

MMAANNNNEERR OOFF DDEEAATTHH

82. After all of the police investigations were complete, the investigating officer, Senior Constable Sims, concluded that there was no evidence any other people were involved in his death.108 I must form my own conclusion in that regard, which then assists in forming my conclusion as to the manner of death.

83. Although the deceased’s family appear to have heard rumours about the possibility of other people being involved, police investigation of those rumours found they could not be substantiated.

84. Ms Hansen, who had known the deceased well for many years and had remained close to him even after their intimate relationship ended, believed the deceased had no known enemies and he had not mentioned any recent fights or ‘fallings out’ to her. When she last saw him on 7 August 2012 he did not seem to be fearful of, or upset with, anything or anyone and in her words he appeared to be “fine and happy.”109

85. Mr Rowe, who seems to have spent the most amount of time with the deceased in the last weeks before his death, was aware of the deceased’s ongoing dispute with the person called Bilyal but did not think they had ever resorted to physical violence to resolve the dispute. The account of Mr Taylor supports the view that they were verbally abusive towards each other but that at least Bilyal wasn’t up to a physical confrontation at that stage, given he failed to attend the arranged meeting at the service station.

86. The lack of any physical evidence at the scene where the deceased was found to suggest a disturbance or that other people had been in that part of the riverbank, as well as the lack of any post mortem evidence of injury to the deceased, also works against any suggestion that other people were involved in the deceased’s death.

87. On the other hand, the available evidence strongly supports the conclusion the deceased voluntarily entered the river on 7 August 2012 to escape the police and, for an unknown reason, got into difficulties and drowned before he could make it safely out of the river on the other side.

88. Counsel who appeared on behalf of the deceased’s family accepted that the most powerful piece of evidence was the fact

108 T 41.

109 Exhibit 1, Tab 6 [126] – [128].

Inquest into the death of Thomas WILLIAMS (892/2012) 21

that the deceased’s body was found “in close proximity to where he was last seen.”110

89. Putting that into the context that it is also not in contest that:

• the deceased had run away from the police in the direction of the river and had a good reason to want to remain hidden from them;

• according to Ms Hansen he had been known to swim rivers to avoid apprehension by police in the past;

• according to Dr Cadden the cause of death was consistent with drowning; and

• other than Mr Harrington’s possible contact with the deceased, which I have found was unreliable, the deceased did not contact any of his family and friends after that time, I am satisfied that the only reasonable conclusion open on the evidence is that the deceased died on the afternoon of the 7 August 2012 in the Canning River while trying to escape from police.

90. In the circumstances, I find that the manner of death was by way of misadventure.

PPOOLLIICCEE CCOONNDDUUCCTT

91. As noted at the beginning of this finding, the deceased’s contact with the police was immediately prior to his last sighting on 7 August 2012. As this raised a concern that the police may have caused or contributed to the death, the matter was subject to an internal investigation conducted by officers from the Internal Affairs Unit, Professional Standards Portfolio, of the Western Australia Police.111

92. The internal affairs investigators conceded that the police pursuit of the deceased could not be discounted as a contributing factor to the deceased’s death. However, the internal affairs investigators also concluded that there was no evidence or intelligence to suggest that police acted inappropriately in this instance.112 The two police officers involved were not found by the internal affairs investigators to have acted unlawfully, breached policy or procedure, nor failed in their duty of care.113

110 T 121.

111 T 20.

112 Exhibit 1, Tab 2, Internal Affairs Report, 9.5.2013.

113 Exhibit 1, Tab 2 and Tab 3.

Inquest into the death of Thomas WILLIAMS (892/2012) 22

93. In a report to the State Coroner, Superintendent Allan Adams noted that pursuing a person wanted for questioning in relation to a suspicious person complaint may cause a degree of stress and cause a person to run, but the police officers were unaware of the identity of the deceased at the time they first approached him and were unaware that he might act in the more extreme manner that he did. Further, the deceased was a considerable distance ahead of the police officer and the police officer only pursued the deceased for a short time, so their involvement with him was limited.114

94. Inspector Thomas Clay, who was an Inspector for the IAU at the time of the deceased’s death, gave evidence at the inquest and confirmed that no breaches of policy, procedure or police duty of care were identified during the internal affairs investigation.115

95. Having reviewed all of the evidence, I am satisfied that the deceased entered the Canning River on 7 August 2012 to escape from the two police officers who were trying to speak to him. To that extent, they could be said to have contributed to his death.

However, in saying that I make no criticism of the police officers as it was reasonable and appropriate for them to try to speak to the deceased, given the report they had received, and to pursue him when he ran away. I am satisfied from hearing their evidence that they did not think that the deceased was so desperate to escape that he would voluntarily choose to swim the river fully clothed, in the middle of winter. They searched the most obvious places, namely on the riverbank and in his friend’s house nearby.

When they were unsuccessful, they left the area. Their conduct was appropriate in the circumstances

CCOONNCCLLUUSSIIOONN

96. On the afternoon of 7 August 2012 the deceased was in possession of illicit drugs and had an outstanding warrant for his arrest. When he saw police officers coming towards him, he made the choice to run. In his bid to escape the police, he entered the Canning River and tried to cross to the other side. For reasons that can’t be determined on the available evidence, while in the process of crossing the river the deceased got into difficulties and drowned.

97. I am satisfied that, while the police officers’ pursuit of the deceased was the reason that the deceased entered the river that day, their conduct was reasonable and appropriate. The 114 Exhibit 1, Tab 2, Internal Affairs Report, 9.5.2013.

115 T 26.

Inquest into the death of Thomas WILLIAMS (892/2012) 23

deceased’s death was a result of his own decision to flee rather than to face his inevitable arrest.

98. The unusual circumstances of the deceased’s death have understandably caused the deceased’s family great concern and added to their grief and distress. It has led to speculation about other possible events that might have intervened from the time the deceased was last seen and when his body was found a week later. However, having explored these issues, I am satisfied that no other person was involved in the deceased’s death and his death was a result of misadventure.

S H Linton Coroner 5 April 2015 Inquest into the death of Thomas WILLIAMS (892/2012) 24