Inquest into the Death of Satwant KAUR

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

RECORD OF INVESTIGATION INTO DEATH Ref No: 41/16 I, Evelyn Felicia Vicker, Deputy State Coroner, having investigated the death of Satwant KAUR, with an Inquest held at Perth Coroners Court, Court 51, Central Law Courts, 501 Hay Street, Perth, on 1-2 November 2016 and 15-16 February 2017 find the identity of the deceased was Satwant KAUR and that death occurred on 5 December 2013 at 16 Edgington Crescent, Koondoola, as a result of Multiple Penetrating (Stab) Injuries in the following circumstances:- Counsel Appearing: Ms K Ellson assisted the Deputy State Coroner Ms R Hartley (State Solicitors Office) appeared for the Department of Corrective Services Mr G Huggins (WAPoL Legal Services) appeared on behalf of the Commissioner of Police Ms B Mangan (instructed by DLA Piper) appeared for Rev. Mark Arney Table of Contents Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 1.

SUPPRESSION ORDER The following Suppression Order applies to all reporting of this matter. Terms of Order: There be no publication of any discussion of any intelligence handling procedures within and across the Department of Corrective Services and WA Police.

INTRODUCTION On 5 December 2013 Satwant Kaur (the deceased) died at her home address in Koondoola as a result of 15 stab wounds to her body and neck inflicted by her Stepson (the Stepson).

She was 57 years of age.

On 23 February 2015 the Stepson was sentenced, following a plea of guilty to the murder of the deceased, to life imprisonment with a minimum of 17 years to be served before becoming eligible for parole.

The Deceased The deceased was born on 11 October 1956 in Singapore.

She was brought up in the Hindu religion and her family remain in Singapore where she also has two daughters.

The deceased met her husband in November 2009 when she was on holiday in Perth to visit her sister. She and her husband to be conducted a long distance relationship with Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 2.

her visiting Perth when she could and the rest of the time communicating by telephone.

In February 2010 the deceased came to live in Perth on a tourist Visa and moved in with her husband at his address in Koondoola. She brought with her one of her daughters.

The deceased and her husband married in May 2010, however, there were difficulties in the early part of the marriage, according to the deceased’s husband, largely because of the behaviour of the deceased’s daughter and antagonism between the deceased’s daughter and his youngest son (the Stepson). As a result of these disputes there were arguments between the deceased and her husband and there were incidents of domestic violence causing the deceased to move to a refuge in Fremantle. She then returned to her family in Singapore.

The deceased’s husband had six children with two sons living in Perth. His youngest son lived with him in Koondoola and as a result of the difficulties with the deceased’s daughter there was a poor relationship between the deceased and her youngest Stepson.

The deceased’s husband originated from Romania and his youngest son’s mother is still resident in Romania. The deceased’s husband had taken care of his youngest son in Perth from March 2004 when he arrived from Romania. He had ongoing trouble with his youngest son related to petty Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 3.

offending, drugs, and stealing money from him. The deceased’s husband employed his youngest son in his business, as he did some of his other sons. He paid him a wage and assisted him financially both in terms of assets and finances. For his age the Stepson was financially well off.

The deceased and her husband reconciled late in 2010 and the deceased returned from Singapore and returned to living with her husband and his youngest son. The family dynamics were always difficult with the deceased’s husband becoming very frustrated with his youngest son’s lifestyle.

The deceased kept house for her husband. He confirmed that on the deceased’s daughter leaving the household, and he and the deceased reconciling they had continued to have a difficult relationship, which had improved remarkably in the early part of 2013.

The deceased kept in touch with her sister and had a very supportive family of origin.

The Events On 5 December 2013 the deceased was at her home address in Koondoola preparing vegetables. She was alone because her husband had left for work and the Stepson had been told to leave the family home by his father, her husband.

Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 4.

The deceased’s husband and the Stepson had argued the previous day and the deceased had been asked by her husband to pack up the Stepson’s belongings for him to collect. He had stayed with a neighbour overnight and smoked methamphetamines.

The Stepson arrived at the family home and demanded the deceased give him access to a significant sum of money he believed his father kept there. The deceased was not able to provide him with access to any money and the Stepson became volatile. The deceased attempted to call the police but was stopped from doing so by the Stepson. She returned to preparing vegetables and the Stepson approached her from behind, causing her to turn around with a knife in her hand.

The knife cut the Stepson and she apologised. He took the knife from her and stabbed her repeatedly while she continued to apologise. The deceased collapsed to the floor and, while she was still alive, the Stepson stood on her neck and stabbed her again in the neck. He then used a chair to break her neck. He searched the house for money and when he could not find any he took jewellery and a watch.

When the deceased’s husband returned home from work he found his wife, the deceased, dead and called the police.

His son was traced to Royal Perth Hospital (RPH) as a result of his cut hand and he admitted killing the deceased. She Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 5.

had been stabbed 15 times to various parts of the body with three to her neck.1 At the time the Stepson killed the deceased he was on bail for offences relating to theft and drugs. He had been bailed to the Koondoola address on 20 November 2013 from Hakea Remand Centre where he had been in custody since 13 November 2013.

The deceased’s husband stated2 he did not know his son had been in jail or gone to court, or that he was bailed to that address on 20 November 2013.3 During the Stepson’s time in custody from 13-20 November 2013 he had made three separate threats to kill his step mother, the deceased.

ISSUES FOR THIS INQUEST Pursuant to section 3 of the Coroners Act 1996 (WA), the death of the deceased was a “reportable death” (g) and must be reported to a coroner (section 17). Section 25 (1) of the Act directs a coroner investigating a death must find if possible -

(a) the identity of the deceased;

(b) how death occurred; and 1 Sentencing Remarks 23 February 2015 Corboy J, SCWA 2 t 1.11.16, p60 3 t 1.11.16, p61, 64 Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 6.

(c) the cause of death; and

(d) the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1988.

Section 25 (2) allows a coroner to comment on any matter connected with the death including public health or safety or the administration of justice; and by subsection (5) a coroner must not frame a finding or comment in such a way as to appear to determine any question of civil liability or to suggest that any person is guilty of any offence.

Section 53 (1) prevents a coroner from holding or concluding an inquest where charges have been laid and section 53 (2) directs that the finding of a coroner on an inquest must not be inconsistent with the result of any earlier proceedings where a person has been charged on indictment or dealt with summarily for an indictable offence in which the question whether the accused person caused the death is in issue.

The issue for determination by this inquest relates to the provisions of section 25 (1) (b) as to how death occurred, in the context of an examination of the threats made by the deceased’s Stepson with respect to his intent to kill the deceased on his release from prison on 20 November 2013.

The need to deal discreetly with the intelligence handling pathways between organisations makes the following summary appear superficial. I believe it provides enough of Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 7.

an outline, but not detail, of the course of events to appreciate the points at which difficulties arose which need to be addressed.

DEPARTMENT OF CORRECTIVE SERVICES (DCS) On 12 November 2013 the Stepson was placed on remand in Hakea Prison for offences of stealing a motor vehicle, possession of a controlled weapon and possession of drug paraphernalia. He was due to attend Joondalup Magistrates Court on 20 November 2013.4 On the Stepson’s admission to Hakea Remand Centre (Hakea) he was placed on the At Risk Management System (ARMS) due to his young age, 19, and the fact it was his first time in custody. Prisoners on ARMS are reviewed by various prison personnel and discussed at Prisoner Review Assessment Group (PRAG) meetings to determine their vulnerability and appropriate placement in the prison system. It was noted the Stepson appeared to be quite confident, although there was some perception this may have been bravado due to his wish to appear to have status in the prison system. He claimed to have friends and relatives in the system he believed would protect him.

Review by the Prison Counselling Service (PCS) on 13 November 2013 determined there were no obvious problems with his placement and he was placed into the 4 Ex 1, tab 10 Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 8.

orientation unit (unit 12) under 12 hourly observations.

PRAG decided he would be placed as a medium security prisoner and he was moved from the orientation unit into unit 9 on 15 November 2013. PRAG, on 19 November 2013, removed him from ARMS pending his court appearance on 20 November 2013.

During his time at Hakea the Stepson made three separate threats concerning the deceased on 14 November 2013, 15 November 2013 and 18 November 2013.

The threat on 15 November 2013 originated from a different source than the threats made on 14 & 18 November 2013, which came from the same source.

The threat on 15 November 20135 was the only threat which entered the Department of Corrective Services (DCS) justice intelligence system (JIS) prior to the Stepson’s release on bail on 20 November 2013 at Joondalup Magistrates Court.

The other two threats were not received by JIS until 25 November 2013 and were not fed into WA Police’s (WAPoL) data management system until 16 December 2013, 11 days after the deceased’s death.6 The threat on 15 November 2013 entered JIS on the day it was made and went through an internal pathway, whereas the threats on 14 & 18 November 2013 were made to an 5 Ex 1, tab 10, attachment 10 6 Ex 1, tab 10, attachment 11 Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 9.

external source and did not enter JIS until 25 November 2013, five days after the Stepson had been released on bail.

Threat made on Friday 15 November 2013 The threat made by the Stepson against the deceased on 15 November 2013 was entered into JIS on 15 November 2013 as the result of communication by both telephone and email. The threat was received by the Security Manager and dealt with immediately. Due to that threat being received on the afternoon of a Friday it was not downloaded for action until Monday 18 November 2013.

The source of the threat notification on 15 November 2013 believed the Stepson to be acting out of bravado and venting, however, believed the threat needed to be communicated as a matter of urgency to JIS.7 The senior analyst downloading the threat on Monday, 18 November 2013 reviewed the nature of the threat, a part of which was “intends to kill his step mother”. He reviewed the status of the Stepson and saw he was due to attend court on 20 November 2013. He determined it was possible the Stepson would receive bail and therefore allocated the matter to an analyst with a turnaround time of 24 hours.8 This should have meant the information in the threat would be “value added” by the analyst and provided to the senior analyst on 19 November 2013, remembering the Stepson 7 t 15.02.17, p209 8 t 15.02.17, p211 Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 10.

was to be before the courts the following day. The system for the communication of intelligence between JIS and WAPoL requires information to be approved by the senior analyst prior to its being submitted to WAPoL.

The analyst to whom the senior analyst allocated the matter reviewed the information and the information available to him via the prison system and determined it was important the threat be passed to WAPoL as soon as possible.

However, this resulted in the information being forwarded to WAPoL on 20 November 2013, not 19 November 2013. Due to the urgency of the matter the analyst sought permission from the senior analyst to email the information directly to WAPoL rather than submitting it to the WAPoL database which required additional time inputting a report compatible with the WAPoL database.

The email was sent to the State Intelligence Division (SID) at 11.25 am on 20 November 2013. Information sent by email and not in a format necessary for direct dissemination on the WAPoL data management system does not enter the system to be accessed by all police officers with access to it until it has been appropriately formatted.

Once the email had been sent to WAPoL on 20 November 2013 it was not reformatted into the WAPoL data management system until 28 November 2013. Having received approval for the information to be submitted to the WAPoL data management system there was no requirement Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 11.

for an additional approval for the information to be placed on the system, it should have followed automatically. The analyst involved certainly understood the need for the information to be sent as quickly as possible, but having sent the email failed to submit the same information in the correct format to the WAPoL data management system until 28 November 2013. This meant the information was not available to the police prosecutor in Joondalup Magistrates Court on 20 November 2013 by way of either of two systems available to prosecutors, despite the 11.25 am email to SID on that date.

This was the first missed opportunity to provide the deceased with warning of the threat before the release of the Stepson. Receipt of the formulated information into the WAPoL data management system on 28 November 2013 was another missed opportunity to warn the deceased of the threat before her death.

Threats made on Thursday 14 November 2013 and Monday 18 November 2013 Two additional threats made by the Stepson against the deceased were made to the same person, an external DCS source, on two occasions in circumstances which made the recipient of the threats unsure of both their veracity and the recipient’s ethical responsibilities. The pertinent part of one threat was “if I can get a gun I will put it to her head” and the pertinent part of the other threat related to “I have told her one day I am going to f…… kill you”. The recipient of this Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 12.

threat considered the Stepson to be an immature 18 year old, expressing anger and hurt arising out of a difficult childhood.9 The recipient of these threats had recorded them on both occasions on confidential internal prison systems,10 but had not taken the matter further by communicating them to JIS or sought advice at the time about what should be done.11 Although the recipient of the threats on 14 & 18 November 2013 was concerned by the threats he did not consider they needed communicating until after he understood the Stepson had been released on bail. While the Stepson was in custody the recipient was less concerned about the implications of the threats.12 On understanding the Stepson had been released into the community, the recipient of the threats on 14 & 18 November 2013 became concerned and sought advice from people within the prison system as to the best course of action. The advice was the threats needed to be communicated to those responsible for JIS.13 The recipient of the threats on 14 & 18 November 2013 provided the content of the threats to DCS staff on 25 November 2013 by way of email.14 When they were received they were uploaded onto the second data management 9 t 01.11.16, p70 10 t 01.11.16, p72 11 t 01.11.16, p73 12 t 01.11.16, p73, 81 13 t 01.11.16, p83 14 t 01.11.16, p80 Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 13.

system from which they were downloaded on 26 November 2013 for assessment.

On this occasion the two threats were given a 7 day turnaround by the senior analyst and provided to the same analyst who had dealt with the threat of 15 November 2013.

That analyst saw all three threats as the same threat and believed that, due to his email on 20 November 2013, the matter was already before WAPoL.15 A 7 day turnaround would have implied the information should have been returned to the senior analyst on 3 December 2013 for approval to be communicated to WAPoL on that date. The 3 of December 2013 was before the deceased was killed and would have been another opportunity to intervene in events, however, it was neither emailed to WAPoL nor submitted to the WAPoL data management system until 16 December 2013, 11 days after the Stepson killed the deceased.

Evidence was heard that the computer access by DCS to the WAPoL data management system was by way of two standalone computers in the analyst section, but could not be accessed from their own desk tops, as it can now.16 To enable an analyst at DCS to place information on the WAPoL data management system it had to be reformatted and then taken to the standalone computer to upload the 15 t 15.02.17, p242/3 16 t 15.02.17, p246 Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 14.

data. Different analysts gave different information as to whether they did that immediately or waited until they had a number of reports to place on the WAPoL data management system. This appeared to be irrespective of the urgency.

From the DCS perspective there were three points at which prompt communication of the 15 November 2013 threat to WAPoL and the deceased could have been communicated prior to the deceased’s death on 5 December 2013.

The threat of 15 November 2013 could have been communicated on;

• 18 November 2013 if given an immediate turnaround;

• 19 November 2013 had the 24hour turnaround been complied with, and;

• 20 November 2013, if uploaded onto the WAPoL data management system at the time the email was sent at 11.24 am.

Communication to the deceased of a threat to her safety could potentially have been provided prior to the Stepson’s release on bail to her home address.

It could also, had it been on the WAPoL data management system, potentially have been available to the bail sergeant to inform the court of a problem with bail for the Stepson on his appearance 20 November 2013 had the data been Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 15.

properly “value added” with a proper address for the deceased.

With respect to the threats of 14 & 18 November 2013, those threats could have been communicated to the deceased had they been uploaded onto the WAPoL data management system on 25 November 2013 or even 3 December 2013, prior to her death. Appropriate reporting of those two threats when they occurred, and appropriate turnaround allocation, could even have allowed WAPoL and the deceased to be informed prior to the Stepson’s release on bail.

Bail The Stepson appeared in Joondalup Magistrates Court on 20 November 2013. The bail sergeant in court on that date advised the inquest that, on any date in the custody list, they may receive applications for bail in approximately 50% of the matters on the list, without notice a person in custody was seeking bail.17 Those custody lists may contain anything between 60-120 matters to be dealt with by the prosecutor in that court. On 20 November 2013 the bail sergeant was dealing with 80 matters. At the time the deceased’s bail application was dealt with, 2.15 pm, there was nothing available to the bail sergeant to alert her to the fact the deceased may be in danger if the Stepson was placed on bail,18 especially to the Koondoola address.

17 t 2.11.16, p119 18 Ex 20 Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 16.

The offences with which the bail sergeant was dealing did not relate to the deceased, and even had the sergeant been aware of the threats, the information available to WAPoL provided a different address for the deceased, than that in which she was actually residing, and to which the Stepson was then bailed.

It so happened the prosecuting bail sergeant on 20 November 2013 had, in 2009, been the domestic violence court prosecutor. The sergeant was therefore well acquainted with the seriousness of threats relating to a family dynamic, and would have been in a position to argue against bail had there been any information available to indicate a domestic violence issue.19 The Stepson sought bail and, because there was no information before the court as to why he should not receive bail on the offences for which he was appearing, it was granted. The Stepson asked to be remanded to his home address in Koondoola. The court suggested his father should provide surety, but the Stepson specifically asked that his father not be asked to provide surety and stated he was in a position to provide his own surety. There was no reason this should not be accepted and the Stepson was released to return to court a week later, with a condition he 19 t 2.11.16, p122 Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 17.

reside at the Koondoola address.20 The address at which the deceased resided.

The deceased’s husband gave evidence he did not know his son had been in jail or was bailed to a court hearing, or had been given the Koondoola address as a bail condition.21 Summary The situation on 20 November 2013, the day the Stepson was released on bail to the deceased’s address, was that DCS was aware of one threat to the deceased, made on 15 November 2013, which was communicated to WAPoL by email on 20 November 2013. It was not in a format which would enter any necessary police databases for relevant distribution immediately. The report in a compatible format was not forwarded to WAPoL until 28 November 2013.

In the following week DCS became aware of another two threats which they saw as the same threat.

As far as WAPoL was concerned DCS had, by 25 November 2013, evidence of three separate offences of threats to kill the deceased by her Stepson. WAPoL was never in receipt of the two additional potential offences from DCS by the time of her death on 5 December 2013.

20 Ex 2, tab 7 21 t 1.11.16, p61, 64 Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 18.

WA POLICE (WAPoL) The email sent from DCS on 20 November 2013 at 11.24 am was received by the supervisor of the South Metro SID at 11.25 am. That officer actioned the email within 17 minutes by forwarding it to the officer in charge (OIC) of the data management system, two level 5 analysts, the OIC of Fremantle Police Station and the OIC of the Fremantle detectives. It was sent to Fremantle because on the information available the deceased appeared on WAPoL databases as residing in Fremantle. That had been her address in 2009 when she had accessed a refuge before going to Singapore and returning to Koondoola in 2010.

When the email was received the information was not transferred into the data management system because it was believed the information in the email would be placed on to the system by DCS as advised in the email. The email stated the information would be placed on the WAPoL data management system as soon as possible. The parties to whom the email was sent also had access to the data management system and could check that data for themselves.22 The sergeant receiving the email at first instance in South Metro SID explained to the inquest that information relating to domestic violence incidents was treated differently by police. The content of the email would be considered, in 22 t 16.02.17, p4 Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 19.

police terms, to be a domestic violence incident and the information should have been disseminated to the relevant family protection unit (FPU). On receipt by the appropriate FPU it would have been triaged according to that unit’s protocols. It would have been up to the FPU to investigate the threat by way of validation and investigation.

The relevant FPU as far as the sergeant was concerned would have been Fremantle and on receipt by Fremantle FPU one would have assumed, on investigation, they would have realised the deceased was not in Fremantle, but Koondoola.

On the information provided to the sergeant there did not seem to be an imminent threat to the deceased while her address was in Fremantle, and the Stepson bailed to an address in Koondoola. It was a matter he expected to be investigated by the Fremantle FPU. His responsibility was merely to disseminate the email which he believed he did.

In hindsight, dissemination to the FPU would have been in accordance with the protocol, rather than the OIC and detectives, but it still would have been to the Fremantle FPU on the information he received.

The email the sergeant forwarded was to the acting OIC of the south metropolitan crime and intelligence coordination unit (CICU). The email from the intelligence supervisor for SID was copied to the acting OIC of the south metro CICU at Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 20.

about 5.36 am on Thursday 21 November 2013.23 On receipt of the email the acting OIC of the south metro CICU was satisfied it had been forwarded to the Fremantle detectives and felt no further action was required by him under the protocols. He became aware of a data management system report on 28 November 2013 with respect to the same email at approximately 2.00 pm on Friday 29 November 2013.

As a result of receiving that information the acting OIC tasked a WAPoL analyst to research information with respect to the deceased. The OIC was informed by his analyst the deceased was not resident in Fremantle, but rather resident in Koondoola. As a result the analyst was directed to allocate the “value added” information to the north west metropolitan CICU as the area responsible for Koondoola. That was also copied to the Fremantle detectives to keep them up to date.

The acting OIC of the south metro CICU indicated CICU does not investigate reports, but rather files them, value adds to them and then allocates them for further investigation. In this case he had ensured the information was value added and then allocated to the relevant CICU, north west metro, to be provided to the relevant FPU.

23 t 16.02.17, p4 Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 21.

Tripartite Agreement There was a tripartite schedule implemented in August 2013 between the then Department for Child Protection and Family Support, DCS and WAPoL which outlined a process for those departments to work collaboratively in the areas of domestic violence. Its purpose was to ensure the exchange of information in a timely manner where it was reasonable to conclude that a person making threats or posing a serious risk to safety and wellbeing of family members, particularly women and children, could then be acted upon in a timely manner.

With respect to the threat made by the Stepson on 15 November 2013, that information was not disseminated to a relevant FPU until 29 November 2013. This was the same time as the properly formatted data came through to WAPoL from DCS. Then nothing was done by that FPU, despite the fact it was a unique FPU in that it had an investigative arm as well as an information function, because it was not the correct FPU once the deceased’s correct address was added.

There would still have been an opportunity for the deceased to have been warned of the threat to herself, from the 15 November 2014 threat received into the WAPoL data management system on 28 November 2014, prior to her death, had the north west metropolitan FPU acted on Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 22.

receipt of that information prior to her death on 5 December 2013.

The reason for the lack of timely action on behalf of the north west metropolitan FPU was that the OIC was absent at the time of receipt of the information from the south west metropolitan CICU, and his replacement was unable to access that particular email stream. Had the officer from the south west CICU been aware of the fact the email forwarding the threat and the fact of the deceased’s residence in Koondoola, had not been received by north west metropolitan FPU, he could have taken alternative action. He did not know and did not take alternative action.

There was no requirement he did more than forward the email.

There is no explanation as to what should have occurred to the properly formatted data forwarded on 28 November 2014.

The other two threats handled by DCS were never provided to WAPoL until after the death of the deceased. Earlier communication would have provided additional opportunities for WAPoL to act on the deceased’s safety which may have provided an additional point at which there could have been intervention for the deceased.

Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 23.

CONCLUSION AS TO THE DEATH OF THE DECEASED There is no doubt the difficulties surrounding communication and relevant investigation of intelligence gathered in one forum and needed to be acted upon in another forum affected the potential for there to have been a different outcome with respect to the deceased’s murder by her Stepson. The lack of effective communication prevented a number of opportunities at which the deceased could, and should, have been warned contact with her Stepson was undesirable.

Instead, a situation was created whereby it was inevitable there would be a confrontation between the Stepson and the deceased, in circumstances where it was obvious the Stepson blamed the deceased for his lack of ongoing support from his father. His lack of insight into the fact it was his behaviour which was the problem is only emphasised by the lack of control he showed and the course of action he took.

The Stepson was directly responsible for the deceased’s death at the time it occurred, no one else. He was a bully and vented his lack of control in a cowardly outburst on a defenceless woman in her own home.

I understand the circumstances of the Stepson making the three threats against the deceased were such that those hearing the threats were cautious about their veracity. The Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 24.

threats did, however, in their persistence, reflect a deep belief in the Stepson that the deceased was to blame for his situation and a total conviction she was somehow responsible for the woes in his life.

I have no doubt the Stepson felt he was in a confronting environment where he wished to look confident. Whether he actually meant what he said was a moot point while he was still in custody.

On his release on 20 November 2013 to the Koondoola address he did not immediately put his threats into action, but there is no doubt in my mind his resentment of the deceased when it came to his manipulation of his father was a serious issue which needed little perceived provocation to erupt. The deceased was ‘walking on egg shells’ metaphorically speaking, and did not know it.

On 5 December 2013 the Stepson had been told to leave the family home by his father. Both the deceased’s husband and the Stepson were angry. Apparently unknown to his father, the Stepson had been bailed to that address as a condition by a court for petty, nasty offences. The Stepson had visited a friend and used amphetamines. He returned home specifically to obtain money he believed his father had which he wanted. The deceased innocently frustrated his actions. His anger and resentment erupted and she died, horrifically.

Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 25.

Had any of the opportunities to convey a warning to the deceased been acted upon before 5 December 2013 there is a significant chance she would not have been exposed to the situation which resulted in her death.

I doubt, having left prison, the Stepson would have consciously set out to kill the deceased. However, his antipathy and immaturity was of a calibre which took almost no confrontation at all for him to take out his feelings of resentment on the deceased. The deceased deserved to know about the threats to her life to put her in a situation where direct conflict could be avoided.

It is easy to see how the perceived lack of clarity for those external to the prison system about reporting “venting” threats may prevent action, but the prison environment is such that threats need to, at the very least, be reported.

It is easy to see how the volume of work for the analysts, both DCS and WAPoL can only be addressed by the introduction of procedures and protocols. But, part of those protocols need to be the ability, where necessary, to effectively act outside the protocols and have the issues addressed. As the police officer receiving the initial incoming email stated, he believed it was the only email of its type he had seen.24 That surely emphasised it was considered to be a significant issue which was time critical and it was necessary someone take carriage of the matter 24 t 16.02.17, p3 Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 26.

rather than merely pass it on. The problem with the protocols is who that needs to be.

It was forwarded to the Fremantle Detectives because they should be an obvious investigative option to act quickly on a life threatening issue. Apparently not. Not their area, either geographically or demographically, so on it shuffled, or not.

The information was received by WAPoL in a proper format according to the protocols by 29 November 2014, but was still not investigated or acted upon to warn the deceased of a threat to herself prior to her death, six days later.

The fact a threat to kill anyone is confined by protocols around the familial relationships of the parties with respect to its proper investigation is a serious flaw in the police domestic violence investigative process. And, in this case, provided for a lack of ownership/responsibility for an investigation, despite the fact the police officer first aware of the threat attempted to alert those he believed to be the most relevant investigators of a potential homicide.

MANNER AND CAUSE OF DEATH In the current case, I have no difficulty in finding the cause of the deceased’s death was multiple penetrating injuries to the deceased’s body and neck.

Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 27.

I find death occurred by way of Unlawful Homicide perpetrated by the deceased’s Stepson.

CHANGES SINCE THE DEATH OF THE DECEASED DCS I note, since the death of the deceased the intelligence gathering analysts in the prison environment have been provided with additional staff to enable them to better streamline the volume of intelligence which flows to the JIS.

In addition, the relevant analysts now have access to the police database necessary for communication of reports considered necessary for action by WAPoL on their desktop, as opposed to having to format and fill out the reports in a different place.

This hopefully would have seen the email sent by the analyst to WAPoL at first instance followed immediately by the appropriate report. This may have facilitated its direct distribution in accordance with the police protocols at an earlier time. Hopefully, when the OIC of the relevant FPU was in a position to access the data stream.

I have also been provided with an outline of DCS directions to external parties as to how to adequately respond to, and forward appropriate information to DCS to enable concerns to be communicated in manner timely to the information.

Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 28.

Police I was not provided with any indication WAPoL considered there was any need to change their protocols to allow for direct communication of a perceived threat to an entity which could investigate despite the protocols. While WAPoL is working with databases which do not communicate with one another effectively, perhaps for valid security reasons, and do not provide access to officers needing to implement actions when acting in positions which should have access, I see little prospect of a more flexible approach to ownership/responsibility for ensuring matters are acted upon and appropriate investigations finalised.

Certainly one police officer did ask for additional information which enabled a judgement to be made that Fremantle was not the appropriate investigating office in the circumstances which arose. However, that should not have prevented someone from ensuring action was taken, rather than relying upon protocols which make FPUs the only units with ownership, without provision for others to be involved.

To an outsider it seems quite remarkable that an FPU should be seen as solely responsible for threats to kill, intrafamilial or not, and of those apparently south west metro is the only FPU with an investigative arm.

Only WAPoL can provide appropriate responses to these types of threats and only WAPoL can devise sensible Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 29.

workable responses to ensuring proper ownership of investigations. Ownership and responsibility do not appear to have been a priority in investigation in the scenario seen in this case. The one police officer who did attempt to secure a positive outcome, outside the protocols, appears to have been the only one who saw a need to try and broaden the potential for intervention, unsuccessfully.

BAIL In the circumstances facing the court on 20 November 2013 there appeared to be no good reason not to grant bail to the Stepson. There was no information available upon which the court could refuse bail or require no contact provisions with the deceased.

It is of concern, however, a young offender, as the Stepson was, could nominate an address without some indication it was an appropriate address. The fact he specifically did not want his father involved was noted by the court to be odd, but was no good reason, without more information not to grant bail for the given offences.

RECOMMENDATIONS Recommendation No.1 Bail should only be granted where the residents of the address at which the Bailee intends to reside have been consulted and consent to the Bailee residing at the address.

Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 30.

Recommendation No.2 Proper investigation of a threat to kill any person should not be confined to police FPUs even when involving intrafamilial parties.

E F Vicker Deputy State Coroner 31 July 2017 Inquest into the death of Satwant KAUR (F/No: 1417/2013) page 31.