Inquest into the Death of Scott Andrew BLANCHARD

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

RECORD OF INVESTIGATION INTO DEATH Ref No: 26/18 I, Evelyn Felicia Vicker, Deputy State Coroner, having investigated the Scott Andrew BLANCHARD death of with an Inquest held at Perth Coroners Court, Court 51, Central Law Courts, 501 Hay Street, Perth, on Scott Andrew 15-16 August 2018 find the identity of the deceased was

BLANCHARD and that death occurred on 24 July 2015 at Kalgoorlie Regional Hospital, as the result of Gunshot Injury to the Chest in the following circumstances:- Counsel Appearing: Ms K Ellson assisted the Deputy State Coroner Ms N Eagling (State Solicitors Office) appeared on behalf of the Commissioner for Police Table of Contents Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 1.

INTRODUCTION On 24 July 2015 Scott Andrew Blanchard (the deceased) was an on duty police officer as part of a Gang Crime Squad (GCS) operation supervising the activity of an outlaw motorcycle gang (OMCG). The operation required some members of the GCS to travel to Kalgoorlie. Shortly before arriving in Kalgoorlie the convoy of officers stopped for a break and the deceased walked a short distance into the bush before using his operational firearm to shoot himself in the chest.

The deceased was 45 years of age.

The circumstances of the death were deemed by the State Coroner not to fall into the provisions of section 22 (1)(b) of the Coroners Act 1996 (WA) (the Act), however, she believed an inquest was desirable under section 22 (2) of the Act in order to clarify the circumstances, as to how the death of the deceased occurred, for the purposes of section 25 of the Act.

The State Coroner directed the authorisation of a firearm to the deceased and observations of the deceased’s colleagues as to his demeanour prior to his death be examined.

In addition, in March 2012, the then State Coroner had issued recommendations with respect to the suicide of a serving police officer as to the availability of health and welfare information to police officers and their families. It was considered by myself the effect of that recommendation in current policing warranted some scrutiny.

Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 2.

The inquest received documentary evidence by way of two briefs, exhibits 1 & 2 and in addition the oral evidence of four police officers travelling to Kalgoorlie with the deceased on 24 July 2015. Evidence was heard in a closed court from the deceased’s wife and a reviewing psychiatrist to assist the inquest with evaluating the deceased’s state of mind on the date in question.

THE DECEASED The deceased was born on 8 July 1970 and grew up in Inglewood, Western Australia, as the oldest of three children.

He worked in a bank and as an exploration driller’s assistant before joining the WA Police force when he was 24 years of age. He was described as a high achiever and described by all who knew him as someone who appeared to be fit in both mind and body, easy to work with, reliable and empathetic.1 The deceased became a detective in 2006 and was highly regarded in his work. By the time of his death he had achieved the rank of Detective Sergeant and had a very commendable police record.

Personally the deceased was private and relatively reserved.

He enjoyed outside activities such as camping, road trips and the Australian bush as well as cycling, running and keeping fit in the gymnasium. His wife described the only time she 1 Ex 1, tabs 7, 8, 9, 10 & 11 Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 3.

could remember him as being depressed was when he damaged ligaments in his arm and was prevented from his usual fitness regime.

The deceased was married to Justine Blanchard and they had two children, 10 and 12 years old at the time of his death. He also had an older son from a previous relationship with whom he had a good rapport.

Although the deceased’s father had left the family unit while the deceased was still at school, the deceased was known to be concerned about his father’s ailing health in the months prior to the deceased’s death, and the deceased also had other personal commitments related to his family of origin.

Mrs Blanchard advised the court her husband appeared to cope well with his job as a police officer, despite having served time in Derby at a time when there were numerous suicides.

He appeared to manage well with the stressors which are part of all police officers’ lives. The deceased became part of the GCS in 2013 and at the time of his death was co-supervisor of one of the teams in the GCS supervising the activities of the OMCGs.

In May 2015 the deceased attended a conference in Thailand and returned home on 23 May 2015. Following that time he noticed a rash on his back and became concerned he had developed a medical condition when, in early June, he Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 4.

developed cold like symptoms. He attended at his general practitioner (GP) surgery and was tested for a number of ailments including some related to possible infections as a result of the trip to Thailand, such as dengue fever.

Mrs Blanchard explained the deceased recovered from his 'flu-like illness, however, was involved in work with long hours. She did not find out until later he had again visited his GP and been given a prescription for medication for anxiety. When she became aware of this the deceased informed her he had not taken the medication, as he preferred not to rely on pills.

Mrs Blanchard became aware her husband was still concerned about the possibility he had developed a medical condition which was undiagnosed and he discussed this with his wife. The deceased’s wife was aware that testing for various medical conditions had all proved negative, however, understood her husband was still convinced there remained an undiagnosed medical concern.

Unbeknown to Mrs Blanchard the deceased had written the equivalent of a suicide note to his family in June 2015 which was not located until after his death.

Mrs Blanchard did not consider the deceased showed any signs of stress related to his job, although after his death some of his colleagues did recall a difficult and confronting Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 5.

work related incident.2 There was no evidence this had concerned the deceased unduly, and he appeared to deal with it as a normal part of the unpredictability of certain aspects of policing.

The deceased, both as a police officer and privately, used firearms and in July the deceased had checked with his wife as to the location of the keys to the firearm cabinet at home.

Nothing more was said and she assumed he was checking the safety aspects of the home firearms security.

The deceased’s wife had a strong premonition something was troubling her husband and on occasion became quite distressed, only to find her concerns were not realised.

In the timeframe immediately preceding the deceased’s death the family dog had to be euthanised and the deceased’s wife believed his lack of open emotion was unusual. Also, the deceased’s team co-supervisor at work, Detective Sergeant Steven Keady (Keady), believed the deceased was a little more reserved than usual, although when he asked the deceased whether he was alright and needed time off he was reassured the deceased was just tired. He believed it related to the deceased feeling fatigued following the effects of his long term 'flu-like illness.3 2 t 15.08.18, p12 3 t 15.08.18, p13 Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 6.

24 JULY 2015 The Gypsy Joker OMCG had opened a new club house in Kalgoorlie and had arranged a celebratory party. As a result members of the GCS were intending to travel to Kalgoorlie to supervise the event from the community perspective. The plan was for various members of the GCS to travel to Kalgoorlie during the preceding week to ensure there were numbers of officers available in Kalgoorlie to manage the event. The OMCGs were not intending to travel to Kalgoorlie in a run, but rather in small groups and as a consequence members of the police were deployed in small groups to travel to Kalgoorlie.4 The deceased and Keady’s team were one of the teams attending Kalgoorlie and on the morning of 24 July 2015 the deceased was collected from his home address by previous agreement by members of his team. His wife believed he was a little distracted that morning and was concerned he was not his usual self. She sent the children out to say goodbye to the deceased hoping the demonstration of family unity would make an impression on both the deceased and those working with him, in the event she was correct and her husband was distracted.

The deceased and those who collected him travelled into the squad offices to prepare their kit for the journey to Kalgoorlie.

The firearms register indicates the deceased checked out his 4 t 15.08.18, p22 Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 7.

firearm with ammunition as required. There is no doubt the deceased’s checkout and his obtaining of his service firearm were in accordance with police procedure and appropriate for the intended job.5 Once kitted the deceased, Keady and Detective Senior Constable David Fagan (Fagan) left the office in a black Ford Falcon with Fagan driving.6 Also departing the office that morning in convoy were Detective First Class Constable Harry Merttens (Merttens) and Detective Senior Constable Matt Wood (Wood) in a white Toyota Prado, and Detective Senior Constable Carmel Morgan (Morgan) and Detective Constable Scott Dodson (Dodson) in a white Holden Commodore. All police officers were carrying firearms as considered appropriate for their task that weekend.

Fagan, Wood and Morgan did not know the deceased well, however, all found him approachable, easy to work with and a good supervisor.7 Keady had known the deceased for a long time and was not aware of any issues with the deceased, other than his observation the deceased had seemed quieter and withdrawn in the weeks preceding 24 July 2015.8 During the trip to Kalgoorlie the convoy stopped frequently to regroup, rest and refresh themselves and the deceased became the driver of their vehicle following the break at lunch 5 Ex 2, tab 28 6 Ex 1, tab 8 7 Ex 1, tabs 8, 10 & 11 8 Ex 1, tab 7 Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 8.

time. Those travelling with him were aware of him receiving a number of calls which appeared to be work related and communication between those involved in the operation as to the logistics concerning the travel.9 In addition Mrs Blanchard advised she both communicated by text message and spoke with her husband during the journey about normal everyday things, including providing him with the latest test results from his GP which were all normal.

Other police officers who came into contact with the deceased during the course of the journey detected nothing different about his demeanour, he appeared relaxed and alert with respect to the job on hand, and there were no concerns as to his welfare or involvement.

The convoy went through Coolgardie at about 4.45 pm and stopped at a vehicle control point (VCP) shortly out of Coolgardie which had been set up as part of the operation in Kalgoorlie. The deceased was driving the lead car in the convoy with Fagan beside him and Keady in the back. After pulling up at the VCP and having a talk with some of the officers there, they all continued toward Kalgoorlie and Keady noticed the deceased had appeared to be engaging well with the conversations and seemed perfectly happy.10 9 t 15.08.18, p23 10 Ex 1, tab 7 Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 9.

A short while later a Kalgoorlie traffic vehicle approached their vehicles from the east and in the vicinity of the last vehicle, occupied by Dodson and Morgan, turned around and stopped that vehicle. There were some speculation they had spent longer at the VCP and were perhaps speeding in order to catch up to the other two vehicles.

The deceased, as the driver of his vehicle, pulled over and indicated he wished to urinate. All three vehicles pulled onto the north side of the highway while the traffic officers spoke to Dodson and Morgan. All officers in the convoy got out of their cars and stood beside the road until the traffic car left.

The deceased again said he needed to urinate, however, Fagan and Morgan took the opportunity before the deceased.

Both Fagan and Morgan returned to the side of the road before the deceased walked off in the same direction as Fagan.

The sun was setting at that stage and it was becoming dusk.

Keady estimated the deceased walked approximately 30-40 metres into the bush and stood behind a large tree. He could partially see the deceased through the bush and became concerned he seemed to be taking a long time for his proposed purpose.

Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 10.

It was at that point the officers standing beside the road heard what was variously described as a pop, and all police officers recognised it as a gunshot. Initially there was little concern, as it was believed the deceased may have disturbed something in the bush, but on looking in the direction he had last been seen it became apparent the deceased was no longer standing upright, but his form could be seen on the ground alongside the tree.

Fagan started walking towards the bush and Merttens followed. As Fagan walked towards the area in which the deceased had gone he called out to the deceased. Fagan then saw the clothing the deceased had been wearing, apparently lying on the ground. As Fagan approached the tree he could see it was the deceased, lying face down on the ground and that his firearm was on the ground close to his right hand side. It took a moment or two for Fagan and Merttens to register what had occurred and they initially thought he may have been playing a prank until they saw his face and noticed blood coming from his mouth.11 Both police officers then moved to assist the deceased and in the process of rolling him onto his side noticed he appeared to have a gunshot wound on the upper left side of his chest.

Fagan immediately ran to obtain the first aid kit from the vehicles as the others moved into place to assist and commence CPR. Fagan also rang 000 to call an ambulance.

11 Ex 1, tabs 8 & 9 Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 11.

On Fagan’s return to the deceased pressure was applied to the deceased’s wound and CPR continued by those present.

Morgan protected the location of the deceased’s firearm noting it had been moved to assist with resuscitation of the deceased. While all police officers gave a concise account of what occurred, it is clear all officers were traumatised by the event as they registered what had happened.

Keady notified appropriate senior police and provisions were put in place both for the urgent attendance of the ambulance and protection of the scene, with the welfare of the involved officers also considered.

The St John Ambulance (SJA) Service dispatched an ambulance at 5.26 pm to leave Kalgoorlie and attend an area approximately 15 kilometres out of town for a self-inflicted gun wound. Paramedic Simon Jenkins had flown to Kalgoorlie that morning to provide training to volunteer ambulance officers. He was present at the Kalgoorlie SJA depot when the call came through. He decided he would attend with the two volunteers, Simon Young and Matt Neville to assist.12 The SJA personnel arrived at the scene and were directed to the deceased by police officers. Mr Jenkins recorded it as 12 Ex 1, tab 17 Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 12.

approximately 50 metres from the road in lightly wooded scrub.13 The SJA officers took an oxy-viva airway bag, defibrillator and other medical supplies and walked over to where CPR was being performed on the deceased. They noticed a considerable amount of blood. The deceased was unconscious and apparently nonresponsive. The three SJA paramedics treated the deceased in an attempt to stabilise him and, once they had provided life support in an attempt to preserve his airways, placed him on a stretcher and into the back of the ambulance. The deceased was taken priority 1 to Kalgoorlie Hospital with full resuscitation on route. They arrived at the Kalgoorlie emergency department (ED) at 6.03 pm.

The Kalgoorlie Regional Hospital notes indicate treatment to the deceased commenced as soon as he was received into the ED, where an anaesthetist and various doctors were already in attendance. They were, however, unable to save the deceased and CPR was ceased at 6.05 pm.14 I am satisfied all the procedures put in place to ensure appropriate forensic examination of the circumstances of the incident were undertaken by senior police at that point who had gathered to both support and record events.

13 Ex 1, tab 17 14 Ex 2, tab 32 Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 13.

POST MORTEM EXAMINATION The post mortem examination of the deceased was undertaken by Dr Jodie White, Forensic Pathologist of the PathWest Laboratory of Medicine WA, on 29 July 2015 in Perth.

Dr White observed an evident single gunshot injury to the deceased’s left anterior chest wall with an exit gunshot wound to the left posterior chest. Internal examination showed injury to the heart and left lung with collapse of the left lung and blood in the left chest cavity. There were a few scattered soft tissue injuries, presumably from the deceased’s fall, but no other significant pathology identified which would account for the deceased’s death.

Dr White recorded the cause of death as ‘gunshot injury to the chest’.15 Further investigations did not disclose any alcohol or common drugs16 and no significant pathology.

The deceased’s medical history recorded no past history with regard to mental health concerns, with recent issues from June 2015 relating to insomnia, anxiety and a recent chest infection. There was no other pathology detected which may have accounted for the deceased’s medical concerns.17 15 Ex 2, tab 52 16 Ex 2, tab 54 17 Ex 2, tab 53 Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 14.

WA POLICE HEALTH AND SAFETY DIVISION In March 2012 the then State Coroner, Alastair Hope, made a coronial recommendation following the suicide of a serving police officer by firearm that; ‘WA Police take action to better promote information in relation to available services to families of serving members.’18 In response to that recommendation the then Health and Welfare branch of WA Police composed a letter outlining employee assist program (EAP) services available to police officers and their families and sent it to all serving police officers at their home address to ensure families were aware of relevant information.19 The current inquest heard evidence from Ms Fiona Donaldson, Assistant Director Health and Safety Division of WA Police, as to the current position with the services available to serving police officers and their families.

Ms Donaldson explained that the response to the earlier letter in 2012 was that it had not been received well by a number of serving police officers who considered it inappropriate such information be provided to their home addresses. This caused some difficulties for the Health and Safety Division as 18 WATT Finding – Ref No. 6/12 19 t 16.08.18, p67 Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 15.

to how they could ensure that families of serving police officers received information about access to welfare services without antagonising some of the serving police members.

One of the methods utilised since 2012 has been to provide the families of graduates at the academy graduation ceremony with pamphlets and documentation explaining the role of Health and Safety Division and the services it could provide to both serving police members and their families, both confidentially and free of charge.

During her evidence Mrs Blanchard indicated that had she been aware of the confidential access for families to health and safety services she would have used those services in the weeks preceding the deceased’s death because she was worried about him and it had caused her anxiety. This was for a number of personal reasons including his response to his concern he had an undiagnosed medical condition.

Ms Donaldson explained the purpose of the Health and Safety Division was to support and promote the psychological, physical and spiritual health and wellbeing of all WA police personnel through the provision of professional advice, services and programmes. The division was now known as the Health and Safety Division, however, prior to 2014 had been the Health and Welfare Unit.

Ms Donaldson was employed in 2012 and currently oversees the Health and Safety Division which comprises a number of Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 16.

different service areas including the psychological unit, claims unit, welfare unit, including the Chaplin services, locational rehabilitation unit, corporate health unit which runs the gymnasiums and the safety branch.

Ms Donaldson outlined that the psychology unit provided support services and assistance to all WA police personnel and employees, has 6 FTEs as psychologists available for counselling and triage of incidents and complex cases. The psychologists work as a triage system and refer police personnel to external confidential agencies through the EAP if extended work is needed.20 The EAP is free, external and confidential for all WA police officers, employees and their family members, each of whom are eligible for six counselling sessions per person per incident. There is no restriction on access to EAP for multiple incidents.

In evidence Keady advised there was a definite stigma perceived by police officers in accessing psychological services, and a concern that seeking professional help through the Health and Safety Division could in some way impede an officer’s career if they were thought to be overly susceptible to stress and anxiety.21 20 Ex 2, tab 44 21 t 15.08.18, p15 Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 17.

Ms Donaldson assured the inquest that police personnel can approach the EAP without going through the Health and Safety division and that all communication between police officers and psychological services were confidential. In the event a police member or member of their family approached EAP directly there would be no record of that through the division other than a statistic.22 In addition to the psychological unit, the welfare unit supports both employees and their immediate family members with any work related or personal issues which may be affecting their quality of life. Their function is to monitor and provide ongoing support and assistance to personnel on long term sick leave or involved in concerns following critical incidents however defined. The welfare unit coordinates the peer support program which is a program which trains volunteering police officers to provide support to fellow officers as considered necessary by the peer support officers or those approaching them. In addition there are three Chaplins who are non-denominational, although belonging to different denominations, to assist if required.

The Health and Welfare Division produce a number of pamphlets providing information to police officers and their families with respect to the various programs on offer.23 22 t 16.08.18, p66 23 Ex 7A-D Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 18.

In addition, serving police members involved in a police defined ‘critical incident’ are approached following each incident to ensure they are aware of the services available should they wish to use them. This would not prevent a police officer with a personal critical incident (response to something they considered confronting which may not necessarily fall within the definition of critical incident as far as WA Police is concerned)24 from accessing services if they were concerned and it may affect their work.

The Health and Safety Division is also in the process of formulating various telephone applications (‘Equipt’ app) which can be downloaded on laptops or telephones which provide members with the ability to access tools designed to help police officers manage the effects of stress and other concerns to do with their wellbeing. The difficulty for the Division is in how to extend this to family members.

Consideration is being given to a separate family internet for use by families of serving police employees.25 The police officers giving evidence with respect to the current matter had varying success with their use of ‘Equipt’ app, however, it was apparent police officers will download available apps in an effort to see whether the provision of those sorts of applications are useful to their circumstances.

Equipt app was developed by the Victorian Police Force and 24 t 15.08.18 (Merttens) 25 t 16.08.18, p67 Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 19.

made available to police forces across Australia, with Western Australia recording the highest use, after Victoria.26 I am satisfied from the information provided that WA Police Health and Safety Division are actively attempting to engage police officers and their families with assistance in managing stress or issues which may arise in the course of their employment, regardless of the differences in an individual’s resilience or response to various stressors.27 From Mrs Blanchard’s perspective there still remained a difficulty in ensuring that immediate family members understood they could access the same services, confidentially and without charge.

The police officers involved in the current inquest had all accessed the psychological services following this incident to differing degrees. All officers agreed that in their particular, although very different requirements for assistance, the contact had been useful from their perspective.

CONCLUSION AS TO THE DEATH OF THE DECEASED I am satisfied the deceased was a well-respected 45 year old serving police officer, well regarded by his superiors, his peers and those he supervised. He was a well-loved husband, 26 Ex 2, tab 44 27 t 15.08.18, p35 Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 20.

father, son and brother and undoubtedly an extremely valuable member of the community as a whole.

The deceased was a dedicated Detective Sergeant who performed well in a team and communicated effectively as was necessary for the purposes of his profession. It is also clear he communicated well in his role as a husband and father, although he obviously took his role as a provider for family welfare and security very seriously and was protective of his family.

Unfortunately this led to him completely misreading his importance to his family as a father, husband and person, due to his misapprehension of their love for him as a human being above all else. His loss to all concerned is immeasurable and something he did not perceive clearly in his distress.

I am satisfied that as the result of the deceased’s personal and medical concerns he became somewhat obsessive as to his work and private responsibilities. As commented by Dr Adam Brett, Consultant Psychiatrist, it is conceivable the deceased had become delusional about his medical concerns.

While there was nothing concrete at the time, in retrospect it is known that people who are severely depressed may come to hold a belief about something with such intensity that they are not amenable to reason. It was possible the deceased’s thoughts about his medical concerns were held with Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 21.

delusional intensity.28 This is probably most clearly demonstrated in the note in June 2015 located after his death on his telephone.

I am satisfied that in the weeks prior to his death, other than when not directly engaged in a work activity the deceased appeared slightly withdrawn, but nothing which would give rise to a concern there was a threat to his safety. His wife was aware of his apparent introspection, but not to the extent she was objectively concerned as to his mental welfare. She was subjectively concerned he appeared distant, but believed it related to a combination of his work, personal and medical issues. Mrs Blanchard could not have done more to try and impress upon the deceased how much he was loved and how important he was to his family. I am not sure that, in the circumstances of this case, access to family services would have changed the outcome.

There was nothing about the deceased’s interaction with those around him which would lead them to suspect he was a threat to himself or others when he perfectly legitimately checked out his service firearm on the morning of 24 July

2015. Had there been I am satisfied those around him would have acted to protect the integrity of the team’s functionality.

There are occasions upon which welfare considerations outweigh individual considerations, but appropriate support 28 t 16.08.18, p127 Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 22.

to manage personnel through those occasions is essential and ultimately benefits all involved.29 I am satisfied the deceased had formed an intention to take his life some time prior to 24 July 2015 and indeed the evidence, in hindsight, would indicate he had formed that intention sometime in June 2015.

I am also satisfied the deceased was aware of the services of the Health and Welfare Division, as were others, but chose to access his personal GP for a more practical approach to his concerns. The evidence supports the deceased had a good relationship with his GP and was comfortable talking to him about his concerns.30 He became obsessed that those concerns were un-diagnosable, and consequently took matters into his own hands as a way of coping with his perception of his threat to those around him and those he loved. It appears to me he chose a time and place where he believed his actions would be more easily dealt with, and not expose his family to the additional trauma of finding him.

MANNER AND CAUSE OF DEATH I am satisfied on 24 July 2015 the deceased had a plan to take his life at some point and in the afternoon at approximately 4.45 pm made the decision he would put that plan into action when he walked into the bush at the side of 29 t 15.08.18, p15 30 t 16.08.18, p126 Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 23.

the road between Coolgardie and Kalgoorlie. He used his police issue firearm to shoot himself in the chest.

I find the deceased died as the result of a self-inflicted gunshot wound and that death occurred by way of Suicide.

Recommendation I recommend WA Police Health and Welfare Division use the police intranet to emphasise to serving members that their families should be made aware of the availability of its services. The development of a family internet would be beneficial provided there was a way to ensure families were made aware of available services.

E F Vicker Deputy State Coroner 20 September 2018 Inquest into the death of Scott Andrew BLANCHARD (F/No: 8031/2015) page 24.