Inquest into the Deaths of Zaraiyah-Lily HEADLAND and Andreas Hohaia HEADLAND

Coroners Act 1996 [Section 26(1)] Coroner’s Court of Western Australia

RECORD OF INVESTIGATION INTO DEATH Ref: 64 /19 I, Sarah Helen Linton, Coroner, having investigated the deaths of Zaraiyah-Lily HEADLAND and Andreas Hohaia HEADLAND with an inquest held at the Perth Coroner’s Court, Court 51, CLC Building, 501 Hay Street, Perth on 29 - 30 October 2019 find that the identity of the deceased persons was Zaraiyah-Lily HEADLAND and Andreas Hohaia HEADLAND and that both deaths occurred on 20 October 2016 at 10 Flight Vista, Yanchep in the following circumstances: Counsel Appearing: Mr T Bishop assisting the Coroner.

Ms R Hartley (State Solicitor’s Office) appearing on behalf of the WA Police, including Constable Kennelly, Sergeant Cutler, Senior Constable Barnes and Senior Sergeant Pinch.

TABLE OF CONTENTS Inquest into the deaths of Zaraiyah-Lily and Andreas HEADLAND (1299 & 1300/2016) 1

INTRODUCTION

1. Anatoria Takiwa and Jason Headland were married in 2013 and had two children together, Zaraiyah-Lily and Andreas. Their marriage ended on 14 October 2016 at Anatoria’s instigation and against Jason’s wishes.

Zaraiyah-Lily was 5 years old, and Andreas was 3 years old, at the time.1

2. On the afternoon of 20 October 2016, after Anatoria made it clear to Jason that they would not be reconciling, he bought some sedative medication as part of a plan he formulated to kill the children. Jason spoke to Anatoria about an hour later and the nature of the phone call disturbed her. In particular, Jason told her that she would never see her children again.

3. Not long after ending the phone call, Anatoria went to the Joondalup police station with a friend. Anatoria requested that police conduct a welfare check on the children. Anatoria did not contemplate that Jason would harm their children, but she was concerned he might take flight with them and wanted the police to make sure they were safe at home with their grandparents, Douglas Headland and Lois May.

4. After making some enquiries, a police recruit spoke to Jason on the telephone and he agreed to bring the children to the police station.

Reassured by this conversation, the police recruit and her supervisor told Anatoria to go home and they would let her know when they had seen the children and checked on their welfare. However, Jason failed to attend the police station.

5. Further enquiries were made and an address was obtained for Jason in Yanchep. A job was created for police officers to go to his house to check on the children. Tragically, by the time the police officers got there, it was too late. Jason had murdered Zaraiyah-Lily and Andreas prior to police attending. The exact mechanism of their death is unknown, as Jason claims to have no memory of the events, but it was consistent with asphyxiation in a child with drug effect. It is also unknown how long it took each child to die, or their time of death, although it was clear both children had been dead for some time when police forced entry to the house just after 10.17 pm.

6. Jason Headland pleaded guilty to the murders of Zaraiyah-Lily and Andreas and was sentenced to life imprisonment with a non-parole period of 31 years’. The known circumstances of their death were covered in the Supreme Court criminal proceedings and I will adopt the relevant facts as found by the learned sentencing Judge.

7. However, the criminal proceedings did not address the role of the police on the night of the deaths. Section 22(1)(b) of the Coroners Act 1996 (WA) requires a Coroner to hold an inquest if a death appears to have been caused, or contributed to, by any action of a member of the Police Force. It was determined that these deaths fell under this provision, given the questions raised by the delay in police attending Jason’s house after 1 I will often use the first names of people in the finding to avoid confusion, given so many members of the same family are mentioned. The family often called the children Lily and Dre, but I will call them by their full names.

Inquest into the deaths of Zaraiyah-Lily and Andreas HEADLAND (1299 & 1300/2016) 2

Anatoria made a report. Accordingly, I held an inquest at the Perth Coroner’s Court on 29 to 30 October 2019.

8. I made it clear during the inquest that Jason Headland, and Jason Headland alone, is the person responsible for these terrible events. What he did was beyond the contemplation of even his closest family members and they are still reeling from the aftermath of his evil acts. It was apparent that the police officers involved were devastated by these events and are still deeply affected. Indeed, everyone involved in the inquest felt keenly the horror of what occurred and the great sadness that comes from two little children having their lives taken away by someone they trusted and who should have been willing to lay down his life to save theirs, rather than coldly take them away.

9. Rather than an exercise to apportion any blame away from Jason, the inquest was an opportunity to explore the actions of the police to ensure that lessons are learnt from this tragedy in the hope that it may prevent similar deaths in the future. Anatoria, Douglas and Lois all bravely gave evidence at the inquest. They gave their evidence in a measured and straightforward manner. Their willingness to share their memories of events greatly assisted me to understand how the events unfolded and I wish to extend my thanks to each of them for doing so, given how painful having to relive these events and speak about them in public must have been for them.

BACKGROUND

10. Jason and Anatoria had been in a relationship since 2005 and were married in 2013. They lived with Jason’s father, Douglas Headland, and stepmother, Lois May, in a house in Wanneroo. They had their first child, Zaraiyah-Lily, in 2011 and second child, Andreas, in 2012. Over the years the family lived in a number of houses until they built a house at 10 Flight Vista, Yanchep.

They moved into the house in June 2016.2

11. Anatoria had been working on a ‘fly in, fly out’ (FIFO) basis with a catering and cleaning company since October 2015. Her roster was four weeks on and one week off. For much of this time Jason had been the primary carer for the children, with the help of his father and stepmother, Douglas and Lois. When Anatoria was away, Jason and the children would stay with Douglas and Lois, and the family would return to the Yanchep house when Anatoria was home.

12. Zaraiyah-Lily and Andreas had more recently been living with Douglas and Lois while both parents were working away. Douglas believed that Jason and Anatoria’s relationship had been strong for a long time and he was able to observe them closely when they were living with him. He noticed their relationship changed when Jason and Anatoria were both working in the mines on opposite shifts. He had not seen them argue but could tell something was wrong. Jason had eventually told him that Anatoria had said 2 Exhibit 2, Tab 1.

Inquest into the deaths of Zaraiyah-Lily and Andreas HEADLAND (1299 & 1300/2016) 3

that she didn’t love him anymore and Douglas had left them to sort it out between them.3

13. Anatoria recalled that she and Jason began to have relationship issues after Anatoria started working away. He became controlling and jealous. He would get angry if she didn’t send him a text message before going to bed and became upset if she went out for drinks after work with her colleagues. They tried to discuss and resolve these issues, but it was difficult to do so over the telephone. When Anatoria was back home to Perth things would usually improve.4

14. Anatoria said in her statement to police that Jason was never physically abusive towards her or the children, but he would sometimes get very angry and threaten to smack the children when they were being naughty.5 However, I note in her friend Katie Cheeseman’s statement, there is reference to Anatoria writing in her diary “about her relationship with Jason, including past violence and threats.”6 The nature of his conduct while she was away, and her reactions to his conduct as they were separating, also strongly suggest there was at least a level of emotional abuse in the relationship.

15. Douglas believed Jason tried to be a good father but had also felt he had changed and become more self-centred towards the end and would raise his voice at the children more. He admitted that he had, at times, been fearful of leaving Jason with the children alone in the months leading up to their deaths because of his moods and the way Jason spoke to them, given their young age, but he believed the children still loved and trusted Jason.

Douglas had spoken to his wife Lois about him, and she encouraged him to help calm the situation.7

16. Lois confirmed that she had spoken to Douglas, and Anatoria about the way Jason addressed his children. Lois is an elder in the Aboriginal community who works in a cultural liaison role that addresses domestic violence and family trauma and she considered the way Jason spoke to the children to be a form of domestic violence and abuse. Lois indicated that she and Douglas did not have any concerns that Jason was physically cruel to the children but she felt the rage he projected at the children at times negatively affected them. He would also sometimes speak of relatives who had committed suicide and ask whether they wanted him to do the same, which she considered very inappropriate. Lois said that she was afraid to confront him as he was a big person, and a security guard, so she was not sure how he would react.8 However, Lois also believed the children loved Jason and were generally well cared for, even after they moved to Yanchep, and they had never shown any reluctance to be with him.9

17. Jason’s sister, who was very close to both Jason and Anatoria, also provided some evidence that Jason had changed and he had become more aggressive 3 Exhibit 2, Tab 3.

4 Exhibit 2, Tab 1.

5 Exhibit 2, Tab 1 [21] – [22].

6 Exhibit 2, Tab 1 [54].

7 T 128 – 129, 142; Exhibit 2, Tab 3.

8 Exhibit 2, Tab 4 [105].

9 T 140, 142 – 143; Exhibit 2, Tab 4.

Inquest into the deaths of Zaraiyah-Lily and Andreas HEADLAND (1299 & 1300/2016) 4

towards Anatoria. She related an incident when he threw Anatoria’s belongings out of the house in anger and then punched the wall at the front of their house. The incident was in the presence of the children, who became very upset, and also out on the street in the view of neighbours.10

18. Anatoria also had a conversation with her aunt around the time of the separation and spoke of Jason being abusive towards her for the past couple of years, but emphasised it was verbal abuse, not physical.11

19. When she gave evidence at the inquest, Anatoria reiterated that Jason was not normally physically violent towards her, although she did confirm that he had physically assaulted her for the first time a few weeks prior to their separation. Anatoria explained that during an argument Jason had put his hands around her throat. She had told Katie about it when explaining why she had asked for a separation, as it had come as a surprise to Katie to hear that they were having problems.12 Anatoria explained to Katie that Jason was not taking the breakdown of their relationship well and had been “getting quite aggressive,”13 which surprised Katie and led Katie to believe that Jason was not the nice guy she had had thought he was.14

PMH INCIDENT

20. There was a documented incident in January 2016, some nine to ten months earlier, that also gives some further indication that Jason’s behaviour was changing, with an increasing tendency towards aggression.

21. On 8 January 2016 Andreas became very ill with symptoms of gastroenteritis. Andreas had been throwing up from about 6.00 am. Jason had just returned from his swing back at the mines, so Lois let him sleep at first and tended to Andreas herself. At about 8.00 am, Lois woke Jason to inform him that Andreas was ill and to look for some fresh clothes for Andreas, who had thrown up over himself. She put Andreas on the bed and he vomited on the bed. Jason reacted angrily and upended the heavy mattress and “progressively went about trashing the rest of the room.”15 Lois was very surprised at his reaction but she persevered and asked Jason whether he could take Andreas to hospital, as she was supposed to go to work, or whether he wanted her to take him. He did not give her an answer.

Lois then left the room to finish getting ready for work.16

22. When Lois came out of her room Jason met her in the hallway. He was dressed and calling out to his eldest daughter, who was also staying there.

Jason told his eldest daughter to pack the bags and grab Zaraiyah-Lily and Andreas and put them in the car as they were all moving out. Lois was very concerned as she had seen Jason’s rage that morning. Lois explained that 10 Exhibit 2, Tab 5.

11 Exhibit 2, Tab 6.

12 T 9 - 10, 40.

13 T 10.

14 T 11 – 12.

15 T 139.

16 T 139 – 140.

Inquest into the deaths of Zaraiyah-Lily and Andreas HEADLAND (1299 & 1300/2016) 5

she had seen Jason in similar rages before, where he was verbally abusive towards the children, but she had not seem him throwing things around before. Lois was also aware that Jason would sometimes have epileptic seizures and he had previously had a seizure when driving a car with his eldest daughter in the car, so she was very concerned about him driving in his heightened emotional state.17

23. Due to her level of concern for the safety of the children, Lois went out to the car and said to Jason, “If you pull out of this driveway with the children I have no option but to call the police because I work in an area where it’s a duty of care. And I will call the police and let them know that you’ve taken the children in this state.”18 Lois said that, thankfully, Jason listened to her and left the children with her, although he then “took off in a fit of rage.”19 She took both the younger children to a doctor and then got a referral to Princess Margaret Hospital.20

24. Douglas was away interstate at the time, and Lois was aware that Jason rang Douglas and made abusive statements about Lois after she left.

Douglas spoke to Lois and told her that she should let Jason have his children and walk away and let it be, but she was concerned for the welfare of the children, particularly Andreas as he was so unwell, so she chose to continue with her plan to keep the children with her.

25. While at the hospital, Lois spoke to Anatoria at about 1.00 pm and asked if Jason had calmed down. Anatoria told her that Jason was still angry. Lois spoke to Douglas and they agreed that Lois should inform the hospital staff of her concerns about Jason’s behaviour towards the children as Jason was coming to the hospital.21

26. Lois told the treating doctor that she feared for Andreas’ safety while he was in Jason’s care and that she was also fearful for her own safety as Jason was on his way to the hospital. The allegation was taken seriously by hospital staff. The Emergency Department was locked down and security staff were notified. A PMH social worker contacted the Department for Child Protection and Family Support’s Crisis Care Unit (CCU) afterhours service requesting a system search on the family and to seek clarification as to whether the family had any prior contact with the Department. A CCU Caseworker undertook a system search and advised the PMH social worker that there had been no prior contact recorded for the child.22

27. The PMH Social worker apparently attended the hospital and spoke to family members that night. Jason had arrived at the hospital by that time and was stopped by security. Lois noted that it would have been quite a shock to Jason, both as a parent and because he worked as a security guard, but he cooperated with hospital security and agreed to speak to the social worker.

Jason reported that there had been an argument between himself and Lois

17 T 139 – 140.

18 T 140.

19 Exhibit 2, Tab 4 [120].

20 Exhibit 2, Tab 4.

21 T 140.

22 Exhibit 1, Tab 25.

Inquest into the deaths of Zaraiyah-Lily and Andreas HEADLAND (1299 & 1300/2016) 6

earlier that morning and he admitted that the argument had become heated.

He said he was stopped from leaving the house to calm down, which only intensified the argument. He denied ever having hurt his children, or having any intention to do so, and also denied having any suicidal thoughts. He admitted that he did swear around the children, and at times swear at the children.23 He admitted he was under a lot of stress at the time, noting there had been some unfortunate suicides of close family members that had affected him.24 It was also noted that the living situation was causing tension within the family, with the young family of five living with Jason’s father and step-mother while they built their house in Yanchep, which was due to be completed in March 2016. Jason had also just started working a FIFO job with a mining company and said he was tired.25

28. The PMH social worker spoke to Lois, who indicated that Jason had not been physically violent to her but that he had shouted at her and on occasions would swear at the children, which she did not feel was safe. Lois advised the social worker that she had been worried that Jason would hurt himself or the children earlier that day. She was said to have no evidence of this being likely to occur but chillingly, she referred to the recent deaths of children in South Australia as an example of why she was worried.26

29. I say ‘chillingly’ as four days earlier, on 4 January 2016, a father in South Australia had driven to the Port Lincoln pier where he shot his two young sons, aged 4 and 9 months, before shooting himself and then driving the car off the pier and into the ocean. None of them survived. The deaths had been reported in the media nationally, and it is apparent from a conversation Anatoria had with Jason (which I refer to later in this finding) where he made mention of these deaths, that these are the deaths Lois was referring to when she spoke of her concern that Jason might harm his children.27 Tragically, her reference to this case later proved to be telling.

30. Lois said that when she spoke to the social worker they agreed that, as Jason’s mother was now with him as a support person and Anatoria was on her way home from the mines, it was safe to leave the children in Jason’s care so Lois went home. Douglas spoke to Jason afterwards and made it clear to Jason that he was not to return to the house in Wanneroo until Douglas returned home from interstate and they would then have to have a ‘sit down’ to talk about the situation. Douglas was also adamant that Jason would have to apologise to Lois for the insulting things he had said to her.

Jason did later apologise to Lois, and she believed his apology was sincere, so they shook hands on it and the family continued to live at the Wanneroo house with Douglas and Lois until their Yanchep house was completed.28

31. After they moved to Yanchep, Lois noted that they would visit on occasion and the house was in order and the children appeared happy and they did 23 Exhibit 1, Tab 25.

24 T 141.

25 Exhibit 1, Tab 25.

26 Exhibit 1, Tab 25.

27 Exhibit 1, Tab 25.

28 T 141.

Inquest into the deaths of Zaraiyah-Lily and Andreas HEADLAND (1299 & 1300/2016) 7

not have any concerns for their safety, apart from the impact his verbal abuse might have on them.29

32. Anatoria gave evidence at the inquest that Lois had raised a conversation with her about the Port Lincoln deaths when they were discussing what was happening between Anatoria and Jason and Lois had expressed concern.

Anatoria said that despite Lois raising these concerns, Anatoria did not believe Jason would hurt their children right up until the events of that night. Nevertheless, she shared this story with Katie, which concerned Katie.30

33. At the time of the incident, the PMH social worker reported to the Department’s CCU worker that she had no concerns for the safety of the children after speaking with Jason and Lois and also having observed Jason interacting with Andreas; his behaviour was seen to be appropriate and Andreas did not exhibit any fear towards him.31

34. Lois gave evidence at the inquest that she had suggested to the PMH social worker that Jason and Anatoria might benefit from being part of a support group, given Andreas’ chronic illness, which was very stressful for the whole family. Lois gave evidence at the inquest that she personally felt let down by PMH in the sense that more support could have been given to the family due to the stress of Andreas’ illness. However, Lois acknowledged that the social worker did give Lois a card and Lois called her about a week later but the social worker was on leave and Lois said she didn’t follow it up again.32

35. I have viewed the notes of the social worker from PMH that were made at the time of the incident. The assessment was that they were a family experiencing stress due to FIFO work and consequent relationship issues, as well as Andreas’ medical issues and financial issues, which had culminated in a family argument that day. It was noted that Lois and the parents were hopeful it would resolve when they were no longer residing together. Jason was encouraged to access counselling through a GP mental health plan and a note was made that Lois was aware who she could contact through the Department of Child Protection and Family Support if she was concerned.33

36. The Department was advised by the PMH social worker that she had no concerns for the safety of the children after speaking to Jason and Lois.

Given the information provided to the Department by the PMH social worker, Departmental staff deemed that no further action was necessary from the Department and the contact was closed without any contact being made by the Department with the family.

29 T 143.

30 T 12, 41.

31 Exhibit 1, Tab 25.

32 T 141 – 142.

33 PMH Emergency Assessment Social Work Notes dated 8.1.2016.

Inquest into the deaths of Zaraiyah-Lily and Andreas HEADLAND (1299 & 1300/2016) 8

THE SEPARATION

37. Over the final year of their marriage, Anatoria said that her feelings had changed towards Jason and their relationship. On Friday, 14 October 2016, while Jason and Anatoria were both still working away, they had a conversation on the telephone. Jason knew she was unhappy and pressed her to tell him what she wanted. Anatoria said she did not want to discuss it on the phone, but after he pressed her she told him that she wanted a break to think about their relationship. As the conversation continued, she eventually told him that she did not love him anymore. Anatoria recalled that Jason did not take the news well and tried to reason with her. She told him that she would continue to love him as the father of their children, but the other feelings were no longer there. Jason was very upset and was sobbing at the end of the call.34

38. On Saturday, 15 October 2016, Jason rang Anatoria and told her he intended to assign custody of their children to Douglas and Lois. He stated his belief that the children should live with their grandparents while he worked away and they rented out the Yanchep house. He also told Anatoria that she would only get supervised visits with the children and his mother intended to go to court on Monday to get an order to that effect.35

39. Anatoria was very upset after the phone call as she believed Jason would be able to achieve his aim. She rang Jason’s sister and told her what he had said. Jason’s sister told Anatoria that Jason had already spoken to her of his plan and she had told him she was not happy with him. She had seen his mental state deteriorate in the two weeks’ prior, due to relationship issues and frustrations about his work hours, and he had been isolating himself from the children. When Jason had told his sister of his desire to give custody to his father and stepmother, she had told him it was a stupid idea.

He had become angry, then gone quiet and said to her that he was a “defeated man”36 and if his Dad and Lois couldn’t have the kids, then no one would.37

40. Anatoria said she was very worried about the situation and decided to fly back to Perth on the Sunday. She wanted to try to pick up the children and take them to stay with her. Anatoria found out from Jason’s sister that Jason was not due to come back to Perth until the Monday. Anatoria said she decided against taking the children before Jason got back. She did not want to keep the children away from him but understood he might try to keep them away from her. She also didn’t think it likely his family would let her take them and she wanted to keep the peace as much as possible.38 Anatoria said she believed that she would be able to reason with Jason and come to an arrangement for shared custody.39 34 Exhibit 2, Tab 1.

35 Exhibit 2, Tab 1.

36 Exhibit 2, Tab 5 [48].

37 Exhibit 2, Tab 1 and Tab 5.

38 T 42.

39 Exhibit 2, Tab 1.

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41. Anatoria returned to Perth on Sunday, 16 October 2016 and Jason flew back on the Monday. Jason called Anatoria that day and asked her not to go to Douglas and Lois’ place to see the children. He told her that he would come and see her the next day so that they could clear the air before going to see the children.40

42. Douglas had seen that Jason was not coping with the separation from Anatoria and Douglas felt it best that the children stay with them, which they generally did.41 Lois had sensed that the separation had taken Jason by surprise, although it was apparent that Anatoria had been thinking about it for some time. She was aware that they had a planned trip to New Zealand for Anatoria’s mother’s 50th birthday, and Jason became concerned that Anatoria would take the children to New Zealand and keep them there.42

43. Jason and Anatoria had a meeting on Tuesday, 18 October 2016, at Anatoria’s aunt and uncle’s home. Her aunt and uncle sat nearby while they talked. It was apparent that Jason wanted Anatoria to change her mind and come back to the marriage. She told him her feelings had changed and she couldn’t be with him anymore. Anatoria recalled that Jason then asked her if she really wanted to lose her family over this.43 In the context of later events, this statement is very disturbing, but at the time it was not apparent to Anatoria what he meant. Anatoria told Jason that their separation had nothing to do with family, but was between him and her. She felt threatened and upset that he was apparently organising other family to get involved and was worried about the reaction of Jason’s family, as he told her that they were very angry. Anatoria said that she just wanted to leave Jason without involving everyone else.44

44. At one stage during the meeting things became heated and Jason got up and took his shirt off and walked out of the house. He then came back in to the house and told Anatoria not to go to day-care and not to come to the hospital on the Thursday (where Andreas had a scheduled medical appointment for a regular blood transfusion). Jason then left again.45

45. After Jason left, he rang Anatoria’s aunt. Anatoria overheard the conversation on speakerphone. Jason asked that Anatoria not take any money out of their bank account, as he said he needed it for the children’s day-care. Anatoria told him she had no intention of removing money from the account. That night Anatoria stayed with her friend Katie Cheeseman.46 Anatoria told Katie she was trying to get some mediation underway so that they could reach a shared custody arrangement. She was trying not to upset Jason more than was necessary and she felt comfortable that the children were safe with Douglas and Lois while they tried to resolve their issues.47 40 Exhibit 2, Tab 1.

41 T 128 - 129; Exhibit 2, Tab 3.

42 Exhibit 2, Tab 4 [53] – [56].

43 Exhibit 2, Tab 1 [53].

44 Exhibit 2, Tab 1.

45 Exhibit 2, Tab 1.

46 Exhibit 2, Tab 1.

47 T 12.

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46. Jason continued to tell his family he was concerned Anatoria might try to take the children back to New Zealand.48 He pulled the children out of their child care and school early because he was concerned Anatoria was staying nearby and might come and take them from there, and was then driving around with them in his car.

47. Jason apparently approached the Aboriginal Legal Service for advice and he did not get the response he wanted to from them. He told Lois, who was concerned about his behaviour. She suggested he speak to the Family Relationships Centre, which he did. The centre was in the same building where Lois worked, so he came in on Tuesday, 18 October 2016, and Lois looked after the children while he sought professional advice. Lois understood they were suggesting family mediation.49 It appears Jason began to realise he would not be able to exclude Anatoria from the children’s lives and make unilateral decisions for them and this lack of ability to control what would happen after the marriage breakdown played a part in later events.50

48. The next day, being Wednesday, 19 October 2016, Anatoria visited her aunt and uncle again and they went out to lunch together. While they were at lunch, Jason rang the aunt, who handed the phone to Anatoria. He asked her where she was and she told him she was at a local restaurant. Jason said he would be there in 10 minutes and confirmed he had the children with him. Jason arrived at the restaurant shortly after with Zaraiyah-Lily and Andreas. The children sat with Anatoria and her relatives. They invited Jason to join them but he chose to sit on his own and did not speak to Anatoria. After about half an hour to an hour had elapsed Jason stated it was time to go and took the children away.51 Katie Cheeseman recalled that Jason dragged the children away, even though it was clear they wanted their mother. Anatoria was upset at this, but did not stop Jason due to his aggression. She said she was not concerned for the safety of the children as she believed they would be staying with Lois and Douglas.52

49. Anatoria did speak to Jason’s sister afterwards and express some concern about how Jason was behaving around the children. Jason’s sister suggested Anatoria could report it to the police if she was worried.53

50. Later that day Jason rang Anatoria and said he was calling as Zaraiyah-Lily was upset. There was a discussion about the fact it was upsetting for her as her parents were no longer together and Jason then hung up. Jason rang Anatoria again later that night and this time they had a good discussion and by the end of the call they were both fairly calm. Jason invited Anatoria to come to the hospital the next day for Andreas’ medical appointment.54 48 Exhibit 1, Tab 24A, pp. 2 – 3.

49 T 144; Exhibit 1, Tab 24A, p. 4; Exhibit 2, Tab 4.

50 Exhibit 2, Tab 4.

51 Exhibit 2, Tab 1.

52 T 13 - 14.

53 Exhibit 2, Tab 5.

54 Exhibit 2, Tab 1.

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EVENTS EARLY ON 20 OCTOBER 2016

51. On 20 October 2016 the children were still in Jason’s care. He took them to Royal Perth Hospital at about 8.00 am for Andreas to have his blood transfusion that he required monthly. Jason texted Anatoria on his way to the hospital.55

52. Anatoria arranged to be dropped at the hospital by Katie and she met Jason and the children there. Jason seemed calm and the children were happy.

Anatoria felt there was “no tension in the air”56 and said she actually felt comfortable around Jason for the first time in a while. Anatoria wanted to discuss a parenting plan with him and she felt like he was genuinely trying to listen to her.57 They had managed to continue having a civil conversation throughout the day so when Jason invited Anatoria to go with him to visit their home in Yanchep and see the newly installed garden, she initially agreed.58

53. However, as they approached the car Anatoria began to feel uncomfortable and once she was in the car she wanted to get out again. Anatoria told police she tried to remain calm and to get the conversation back to agreeing on a parenting plan but Jason talked about his mother and said that she wanted to kill Anatoria. Anatoria began to feel concerned about her own safety and so she told Jason it was getting a bit late and asked him to drop her at the shopping centre in Joondalup. Jason complied with her request and dropped Anatoria at Joondalup Shopping Centre at about 4.00pm. Although she was concerned for her safety, Anatoria said she did not think there was any potential Jason might harm the children, so she kissed both children goodbye as she left, and told them she would see them on Saturday.59

54. As Anatoria collected her belongings from the front seat, Jason shook her hand and said, “What’s done is done.”60 She thought he was indicating that he had accepted their separation and was just going to leave it at that. Jason then drove off with the children. Anatoria assumed Jason would take the children to Douglas and Lois’ house in Wanneroo now that she was not going with them to Yanchep. Anatoria caught the train from Joondalup to Ocean Reef and met up with Katie. She then returned to Katie’s home.61

55. At about 5.00 pm, Jason went to a pharmacy and purchased Restavit, an antihistamine with a sedative effect. He told the pharmacy staff he was working night shift and needed something to help him sleep. He apparently seemed normal and relaxed during the purchase. In fact, he had formed an intention to kill the children by this time and purchased the medication to aid him in that purpose.62 55 Exhibit 2, Tab 1.

56 Exhibit 2, Tab 1 [89].

57 Exhibit 2, Tab 1.

58 T 30.

59 T 31.

60 T 31; Exhibit 2, Tab 1 [100].

61 T 31 - 32; Exhibit 2, Tab 1.

62 Exhibit 1, Tab 24B, p. 7.

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56. Anatoria spent the night at her friend Katie’s house. While they were watching television Anatoria mentioned to Katie that in the past Jason had told her a story that brings up chilling similarities to Lois May’s comment to PMH staff in January 2016. Anatoria said that during a heated discussion some months before their separation, just after he had argued with Lois, Jason told her about the man who drove off a wharf in South Australia with his two children and Jason then said to Anatoria words to the effect of, “Is that what you want me to do?”63 She couldn’t understand why he mentioned it at the time.64 It would seem from this conversation with Katie that in Anatoria’s mind she had begun to contemplate worse scenarios than him simply taking the children away, although she had not allowed it to crystallise in her mind.

57. Jason telephoned Anatoria at 6.16 pm while Anatoria and Katie were watching television. This was the first time she had heard from him since leaving the car in Joondalup. Anatoria seemed to her friend to be frustrated by the call, complaining that Jason was always calling her, but she said she was going to answer the call as it might be her children wanting to say hello.

Anatoria stood up and walked into the bedroom to answer the phone.65

58. When Anatoria answered the phone it was Jason on the line. She recalled that the first words he said to her were “I’m not threatening you, but this is how it’s going to go.”66 His tone, and the words he used, appeared threatening to her, so Anatoria challenged this statement and said to him that it seemed that he was threatening her. Jason replied, “If you don’t come to the house now ….”67 before Anatoria cut him off and said to him, “You have your family there.”68 He said, “It’s just me and the kids,”69 but didn’t say where he was.

59. Jason then went on as follows,70 “This time, I’m going to threaten you. I’m going to hurt you and your mum and your grandmother. I’m going to break your heart into 50 million pieces. Say goodbye to your kids. This is the last time you’re going to speak to them.”

60. Anatoria said she thought Jason was referring to taking custody of the children. Anatoria could hear the children in the background. Jason put the phone on speaker and Anatoria said she loved them and goodbye. Jason then said, “So that’s it”71 and she said goodbye to Jason and hung up the phone. Just before Anatoria hung up the phone, she heard Jason giggle.72 The phone call ended at about 6.15 pm.

63 T 31; Exhibit 2, Tab 2 [59] – [62].

64 T 40 – 41.

65 T 33; Exhibit 2, Tab 2.

66 T 33; Exhibit 2, Tab 1 [106].

67 Exhibit 2, Tab 1 [108].

68 Exhibit 2, Tab 1 [109].

69 Exhibit 2, Tab 1 [110] 70 Exhibit 2, Tab 1 [110].

71 Exhibit 1, Tab 1 [114].

72 Exhibit 1, Tab 1 [115].

Inquest into the deaths of Zaraiyah-Lily and Andreas HEADLAND (1299 & 1300/2016) 13

61. Anatoria was upset and began crying at the end of the phone call. Katie asked her what was wrong and Anatoria told Katie that Jason was “angry”73 and had been threatening her.74 Anatoria gave evidence that although he hadn’t threatened the children, and she didn’t think he was going to harm them, she had a feeling that something wasn’t right and didn’t want the children to be with him. She also indicated she was concerned he might take them away.75

62. Anatoria told Katie roughly the words that Jason had said to her. Katie said when Anatoria told her this, she froze and got goosebumps and was worried that Jason was going to “do something very bad.”76 She felt that they needed help and told Anatoria they would drive to the police station in the hope the police could check on the children’s welfare and make sure they were with Douglas and Lois.77 Anatoria agreed to let Katie drive her to the police station. She said she wanted to ask the police to check on the children and make sure they were there in Wanneroo and happy.78 Katie recalled that Anatoria was very stressed on the journey there. They first drove to Clarkson Police Station, which was closed, so they then drove on to Joondalup Police Station. They arrived at the station at approximately 6.45 pm.79

63. Anatoria indicated that she had never been to a police station before to make a report, nor even called the police for assistance, so it was a foreign environment for her and she was not entirely clear what role the police could perform. However, the general plan was to request that the police check on Anatoria’s children as she wanted to make sure the children were safe.80 Anatoria was nervous and possibly in shock, so she let Katie do most of the talking for her. When asked what she wanted the police to do, Antonia said she wanted them “to check on the children.”81

INITIAL POLICE REPORT82

64. Police Recruit Georgina (Gina) Kennelly had only been with the WA Police a few months at the time of these events. She had been injured during her academy training so she had not graduated with her class and needed to return to the academy to complete her training once she had fully recovered.

Recruit Kennelly had been working at Joondalup Police Station since August 2016, doing front counter duties as she was not allowed to go out on the road until she finished her academy training.83

65. While working at Joondalup Police Station, Recruit Kennelly’s direct supervisor was Sergeant Bradley Cutler. Sergeant Cutler had been with the 73 Exhibit 2, Tab 2 [73].

74 T 15.

75 T 33.

76 T 15.

77 T 16.

78 T 33 - 34.

79 T 16; Exhibit 2, Tab 1; Exhibit 2, Tab 2.

80 Exhibit 2, Tab 1; Exhibit 2, Tab 2.

81 T 34.

82 I note some of the police officers have changed rank, and one of them has married, since these events. I will refer to them by the rank and surname they held at the time.

83 T 45.

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WA Police for 25 years at the time and had been stationed at Joondalup Police Station for about six months as a supervisor in one of the local policing teams.84

66. On Thursday, 20 October 2016, Recruit Kennelly had commenced her shift in the afternoon. Sergeant Cutler was also on duty and was the Officer in Charge of the Joondalup Policing Station.85 Like most days, it was busy at the station during the shift. Recruit Kennelly recalled that she was approached by one of the Customer Service Officers to come and speak to Anatoria and her friend Katie. Recruit Kennelly recalls coming out to meet Anatoria. In her statement, Recruit Kennelly noted that Anatoria “seemed agitated”86 and her friend appeared to be comforting her. In her oral evidence, she said they were both calm and composed although they were obviously uncomfortable.87

67. Primarily through her friend Katie, Anatoria told Recruit Kennelly that she had concerns for her children because she had received a phone call from her husband about half an hour before saying that she “was never going to see the kids again”88 and he was trying to get the kids to say goodbye to her on the phone.89 Recruit Kennelly immediately had a sense that something wasn’t right, which she described as a “weird feeling about it.”90

68. Recruit Kennelly said that her “initial thought was that he was going to do a runner with the kids.”91 Recruit Kennelly quickly took down some personal details and then went and spoke to her supervisor, Sergeant Cutler. She spoke to Sergeant Cutler in his office and gave him a brief account of what Anatoria had told her. She stated she also told him that she “just didn’t feel right” and thought that they should consider ‘putting on a job’.92 Recruit Kennelly explained at the inquest that she was primarily concerned because children were involved, and she “just felt uncomfortable”93 and “got a feeling”94 about it, without being able to explain why.

69. Sergeant Cutler noted in his statement there was “no direct threat to harm the kids”95 in the account given by Anatoria and he felt that what Jason was reported to have said could be taken a few ways. Sergeant Cutler said he took it to be more of a reference to a custody dispute than a possible threat to harm the children.96 Nevertheless, Sergeant Cutler suggested they should speak to the District Control Centre, which was co-located in the same building, about maybe creating a job. They left Sergeant Cutler’s office and went next door together to talk to someone in the DCC.97

84 T 79.

85 T 79.

86 Exhibit 1, Tab 21, p. 9.

87 T 47.

88 Exhibit 1, Tab 21, p. 10.

89 Exhibit 1, Tab 21, pp. 9 - .

90 T 48.

91 Exhibit 1, Tab 21, p. 13.

92 Exhibit 1, Tab 21, p. 14.

93 T 49.

94 T 49.

95 Exhibit 1, Tab 22, p. 9.

96 T 85.

97 Exhibit 1, Tab 21, pp. 13 – 15.

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70. Although their initial statements indicated that they were talking to DCC about possibly ‘putting on a job’, Sergeant Cutler said in evidence at the inquest that he did not approach the DCC with that in mind. He said he was raising it with them more as an “information sharing”98 exercise to give them some notice that it was a possibility that a job might need to be created in the future. He agreed that he would not do such a thing for all jobs that came across the front counter, and I note that the officer they spoke to at DCC considered it an unusual event. Sergeant Cutler indicated that it was because of the nature of the job, involving two children, and because of what had been said to their mother by their father, which he knew meant they would have to be looking into it further and so he advised the DCC as a ‘courtesy’. He agreed that this was because it was possible that they would need some resources for a job at some stage.99 I comment later that his conduct, and his earlier statements and those of other witnesses, are more consistent with Sergeant Cutler contemplating putting on a job at that time.

71. Recruit Kennelly said that they went immediately to the DCC as she didn’t feel right and she wanted something to happen. In her words, she wanted “to just see what we can do to get this ball rolling, to see … what options we had with the limited information we had at that time.”100

72. Recruit Kennelly and Sergeant Cutler spoke briefly to Acting Sergeant Christine Darlington (now Barnes) at sometime around 6.45 pm to 7.00 pm.

A/Sergeant Darlington recalled it was a busy night for the district.101 Recruit Kennelly explained that a lady had presented to the front desk expressing concern about her children. She also relayed the words the father of the children had said about the mother never going to see the children again.

Recruit Kennelly recalled she also indicated she had a bad feeling about it.102

73. A/Sergeant Darlington said she recalled both Sergeant Cutler and Recruit Kennelly seemed calm and were expressing no unusual concern, although she did acknowledge it was unusual for a supervisor to come in with such a query. She used a similar term to Sergeant Cutler, describing it as “a bit of information sharing.”103 A/Sergeant Darlington recalled that one of the two then asked her “Do we put a job on?”104 She responded, “Well, yes, we can get a job put on but where are we going?”105 She told them that they needed to get some more information before a job could be entered, in particular the address and who was involved,106 and she specifically asked them to ask Anatoria if she had made any attempts to locate the children.107 Sergeant Cutler said he agreed with this advice.108

74. A/Sergeant Darlington acknowledged that if she had an address at the time she would have been able to put a job on, in which case the time for police to

98 T 83.

99 T 82.

100 T 50.

101 Exhibit 1, Tab 23, p. 7.

102 Exhibit 1, Tab 21, p. 17.

103 T 157.

104 Exhibit 1, Tab 23, p. 13.

105 Exhibit 1, Tab 23, p. 13.

106 T 158.

107 Exhibit 1, Tab 21, p. 17 and Tab 23, pp. 13 - 16.

108 Exhibit 1, Tab 22, p. 12; Exhibit 2, Tab 11 [7].

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attend would have been approximately an hour.109 However, she considered it was premature to move towards that step at this stage.

75. Recruit Kennelly said she was in two minds when she received this advice, as she was very junior and understood she needed to follow the advice of a sergeant, but she also still had the feeling that she really wanted something done. Recruit Kennelly said she immediately returned to the front counter to speak to Anatoria, as instructed, to try to get more information.110

76. Recruit Kennelly recalled Anatoria started talking to her as soon as she returned, although she appeared calmer by this stage. Anatoria explained that she had been with Jason in the car earlier that day with the intention of talking about the children and he had indicated he wanted to reconcile.

Recruit Kennelly said she was still concerned and wanted her supervisor to come and join in the conversation at this stage. She was intending to go and get Sergeant Cutler, but was saved the trouble as he joined them of his own volition at that time. Recruit Kennelly estimated he joined them at about 7.00 pm.111

77. Sergeant Cutler’s recollection was that he actually accompanied Recruit Kennelly out to the front counter immediately.112 I don’t think anything turns on this slight difference in recollection.

78. While both Sergeant Cutler and Recruit Kennelly were present, Anatoria explained that both she and her husband were FIFO workers and they had separated three days earlier but there were no Family Court proceedings on foot yet. She explained the children had been living with their paternal grandparents for the past two to three weeks, so Recruit Kennelly asked for the grandparents’ contact details. Anatoria provided the names of Jason’s father, Douglas Headland, and step-mother, Lois May, and gave their address and telephone numbers.113 Recruit Kennelly also made a note of Jason’s telephone number and the fact he was said to have “epilepsy and a temper.”114 Recruit Kennelly understood from her conversation with Anatoria that Jason and the children were all living with Douglas and his wife at this time.115

79. Sergeant Cutler recalled that Anatoria’s demeanour at this stage was not “distraught by any means”116 and he did not detect any urgency about the situation. He recalled that Anatoria mentioned she had rejected Jason’s attempt to reconcile that afternoon at about 4.00 pm when they were in the car together, and she had got out shortly after and left Jason with the children.117 Sergeant Cutler said he recognised that it can be upsetting when families split up, but didn’t see it as anything more concerning than that at

109 T 159.

110 T 52; Exhibit 1, Tab 21, p. 21.

111 Exhibit 1, Tab 21, p. 23.

112 T 83; Exhibit 1, Tab 22, p. 15.

113 Exhibit 1, Tab 21, pp. 27 – 29.

114 Exhibit 1, Tab 21, p. 30.

115 Exhibit 1, Tab 21, pp. 30 – 31.

116 Exhibit 1, Tab 22, p. 16.

117 Exhibit 1, Tab 22, p. 17.

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that stage.118 Sergeant Cutler recalled that Anatoria or Katie mentioned concern about wanting to get Anatoria’s car back from Jason, which he thought was surprising in the context of what else they were discussing.119 I note Recruit Kennelly recalled this issue being raised a bit later in the timeline.

80. Sergeant Cutler said he understood from the conversation that the children had been staying with their grandparents and he asked her if she had called them. Anatoria said she wasn’t comfortable calling them herself given the marital separation, on the basis she thought Jason’s parents were a bit upset. He also formed the impression Anatoria did not want to speak to Jason either.120

81. At that stage, Sergeant Cutler recalled that Anatoria had indicated she wasn’t sure where Jason might be, but the only possible address she provided was Douglas Headland’s address in Wanneroo.121 He said in his evidence he did not consider sending a car to that address at that stage as it could be dealt with much more quickly through a phone call, and there was no guarantee that the children were at the address.122

82. Sergeant Cutler’s evidence was that, in his judgment, it did not appear to be an urgent matter at that stage and he felt the appropriate response was to make some telephone calls and do some background checks and see if it could be resolved that way. He emphasised that at that time, there did not appear to him to be any imminent threat to life, based upon the presentation and demeanour of the two women at the counter and the information they provided.123 Sergeant Cutler explained that he had interpreted Jason’s statements to Anatoria about saying goodbye to her children and never seeing them again in the context of a custody dispute. Therefore, his “take on it was, “Good luck seeing your kids again”124 on the basis he would withhold access to them.

83. Recruit Kennelly and Sergeant Cutler left the front counter and went into Sergeant Cutler’s office. Recruit Kennelly said she was going to try to ring Douglas Headland and Sergeant Cutler agreed. Anatoria had provided the number for both Lois and Douglas.125 Recruit Kennelly tried to ring Douglas’ number but he didn’t answer. She then rang Lois, who answered the phone.

Recruit Kennelly asked to speak to Douglas, and he came onto the phone.

Douglas Headland appeared reluctant to speak to Recruit Kennelly and she was uncertain why that was, but thought it was probably because she was a police officer, and possibly also because she was female.126 She asked him if the children were there, and he responded by asking her why she was 118 Exhibit 1, Tab 22, p. 18.

119 Exhibit 1, Tab 22, pp. 18 – 19.

120 Exhibit 1, Tab 22, pp. 20 – 21.

121 Exhibit 1, Tab 22, pp. 19 – 21.

122 T 87.

123 T 84.

124 T 85.

125 T 18.

126 T 53.

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asking. Recruit Kennelly told him that she just wanted to check on the welfare of the children, to which he again asked why.127

84. Recruit Kennelly explained that Anatoria was at the station and there was some concern for the children. Douglas Headland told her that the children were not there. She asked him when he last saw them, and he again asked her why. Recruit Kennelly told him that it was because she had concerns for the children. Mr Headland said that the children were with their father, Jason, and he hadn’t seen them since yesterday.128

85. Recruit Kennelly said she asked Douglas Headland if he had Jason’s address, because as far as she was aware they all lived at Douglas’ address in Wanneroo. She recalled asking if there was another address, and he said he didn’t know where they lived. Mr Headland again asked “what’s with all the questions?”129 At this point, Recruit Kennelly asked to put him on hold, and then she had a quick discussion with Sergeant Cutler and explained Mr Headland was not being forthcoming with information and was questioning why the police were calling him. She thought he might be more comfortable talking with her sergeant.130 Sergeant Cutler indicated she should put the call through to him.131

86. Sergeant Cutler spoke to Douglas Headland on the telephone. He explained again that Anatoria was at the station and she had concerns for her children due to a conversation she had had with Jason. Sergeant Cutler recalled that Douglas Headland indicated that Anatoria’s concerns for the children were unwarranted and the problem lay with Anatoria as the instigator of unrest rather than Jason. It was apparent to Sergeant Cutler that Douglas Headland was unhappy with Anatoria due to the separation.132

87. Sergeant Cutler reiterated that the main concern of the police was to make sure the children were okay so they needed to check on the children. He asked if the children were at Douglas’ house and Douglas said that Jason and the children were not there. Mr Headland did not disclose an alternative address but simply said words to the effect that, “You’re the police, you should know where they are.”133 After a short two to three minute conversation, during which Sergeant Cutler reiterated the need for police to see the children in order to resolve the matter, he ended the call.134

88. Sergeant Cutler said that his conversation with Douglas Headland did not raise the level of urgency in his mind or heighten any concerns, as the children’s grandfather’s impression was that the concern expressed by Anatoria was unwarranted.135 However, he still knew that police officers 127 Exhibit 1, Tab 21, pp. 31 – 32.

128 Exhibit 1, Tab 21, p. 32.

129 Exhibit 1, Tab 21, p. 33.

130 T 53 - 54.

131 Exhibit 1, Tab 21, pp. 33 – 35 and Tab 22, p. 23.

132 T 87; Exhibit 1, Tab 22, pp. 24 - 26.

133 Exhibit 1, Tab 22, p. 24.

134 Exhibit 1, Tab 22, pp. 24 - 26.

135 Exhibit 1, Tab 22, p. 25.

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would need to sight the children before the matter could be resolved and all concerns allayed.136

89. Douglas’ memory of events was a little unclear, but he explained that he had spoken to Jason earlier that afternoon and Jason had said he was at the house in Yanchep with the children. It wasn’t clear to Douglas whether Anatoria was also with them. Jason told Douglas that he wanted to “chill out”137 at the Yanchep house for a while. Douglas had assumed Jason would eventually come back to the Wanneroo house that night.138 When the police called asking about Jason’s whereabouts, Douglas said he couldn’t recall the address as he only knew how to drive there. He agreed he told Sergeant Cutler that he should know the address, but said in his evidence that he “didn’t mean to be cheeky,”139 and wasn’t trying to be unhelpful, but honestly thought that police would have access to that information.140 Douglas did, however, agree that he thought a welfare check on the children was unnecessary and that he said words to that effect to the police.141

90. Douglas indicated in his statement that after speaking to Sergeant Cutler he called Jason at about 6.00 pm (although it would appear his time estimate is not accurate) to tell him the police had contacted him and Jason said he would put the kids in the car and come straight to Douglas’ house. It would seem from Lois’ evidence that she was actually on the phone to Jason at the time.

91. Lois gave evidence as well and she was a very thoughtful and impressive witness. It was clear Lois had a better recollection of events than Douglas, so to the extent that their evidence conflicts, I have adopted Lois’ account as correct. I do not mean to suggest that Douglas was not being honest in any way, but only that he conceded his memory of events was not very good, and even in his statement to police it is clear that he was a little confused about the chronology. Given he would have been in a state of shock, this is entirely understandable.

92. Lois had spoken to Jason in the afternoon to check how Andreas had gone at the hospital. She asked Jason if he was going to come to their home, as he had been sleeping on their couch for the past two weeks with the children.

He said that he probably would. She was surprised they were not home when she got home. She spoke to Douglas, who told her that Jason had gone to Yanchep and she believes Douglas said Jason might stay the night there.

Lois mentioned in her statement that she wondered if this was the best idea, given Jason’s statement of mind. She asked Douglas whether he thought they would be okay, and Douglas reassured her by saying, “Well, why wouldn’t they be? They’re with their Dad.”142

93. Lois explained that they were a big blended family, and for those last few weeks in particular, they had had a full house. Andreas and Zaraiyah-Lily 136 T 106; Exhibit 1, Tab 22, p. 26.

137 Exhibit 2, Tab 3 [36].

138 T 129 – 130; Exhibit 2, Tab 3.

139 T 131.

140 T 131 – 132.

141 T 133.

142 Exhibit 2, Tab 4 [72].

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were sleeping with Douglas and Lois in their bed and they had a daughter and three other grandchildren sleeping there as well. When Douglas told Lois that Jason and the children were staying in Yanchep, they were also aware that her daughter and sons were at the movies, so they were relieved to have the house to themselves for a few hours. They were planning on sharing a rare moment of peace and quiet, which no one could possibly blame them for.143

94. When they received the phone call from police that night, Recruit Kennelly first spoke to Lois. She told her that Anatoria was at the station and she wanted to know if the children were with them. Lois handed the telephone to Douglas as she said she didn’t want to interfere as she is a stepgrandmother and she didn’t want to overstep the mark.144 Douglas was on the phone at the time to Jason, so he handed his phone to Lois.

95. Lois told Jason the police were on the phone wanting to know where the children were, because Anatoria was at the police station. Jason replied, “Oh, is that so?” and seemed quite calm. Lois suggested he come to their house. Jason said that Andreas was already asleep but he would wake him and bring the children from Yanchep to their house in Wanneroo and sleep on the couch.145 Douglas and Lois were both reassured by the fact that Jason was going to bring the children back to their house, so they were not worried at this stage and did not do anything more initially.146

96. As to not providing the police with the Yanchep address at this stage, Lois gave evidence that it was quite genuine of Douglas to say that he didn’t know the address as they knew the street but not the number. However, Lois was also frank in her evidence that there is a lot of mistrust between Aboriginal people and the police and she believed there was probably an element of that too. She explained further, saying “we’ve all had really negative experiences with police, so you know, when police are involved and involved with our families we, kind of, put up a barrier.”147 Lois gave evidence that if the police had pushed them for further details, or come to their house and impressed upon them that they had real concerns for the children’s safety, she believes they wouldn’t have hesitated to go to Jason’s house. However, looking back they are also realistic that if they had done so on their own, there would likely at least have been a confrontation with Jason, and potentially he might have harmed them as well. Lois was very honest about the fact that she and Douglas have rehashed the events over in their minds and hearts countless times to wonder if there was more they could have done, but at the time they honestly thought that the move to Yanchep had been a positive step for Jason and the children and they had no concerns that he would deliberately harm them.148

97. Around this time Recruit Kennelly believes she conducted some checks on the police computer system and identified that neither Anatoria nor Jason

143 T 146.

144 T 143; Exhibit 2, Tab 4.

145 T 145; Exhibit 1, Tab 24, p. 5; Exhibit 2, Tab 4 [77] – [82].

146 T 134.

147 T 145.

148 T 147 – 148.

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had a police record and their registered address was Douglas Headland’s address in Wanneroo.149

98. After Sergeant Cutler finished speaking to Douglas on the telephone he spoke to Recruit Kennelly and then returned with Recruit Kennelly to the front counter. Recruit Kennelly recalled that it was at this time that Anatoria started speaking about her car. She said Jason had the car, which was registered in her name, and she wanted to know if the police could get the car back for her. The police explained it was joint property so there was little they could do.

99. At this stage Anatoria’s mobile phone was ringing. It was just before 8.00 pm, and about an hour had elapsed since Anatoria had arrived at the station.150 Anatoria told Recruit Kennelly that it was Jason calling her.

Recruit Kennelly told Anatoria she could answer the call, but Anatoria said she didn’t want to answer it and became more agitated. Recruit Kennelly asked if she could take the call, and then she received the telephone from Anatoria. As Recruit Kennelly went to answer the call, it stopped ringing.

She tried to call back but it didn’t connect through, possibly because Jason was trying to call again. Recruit Kennelly had gone out to speak to Sergeant Cutler at this time and she spoke to him just before she managed to answer another incoming call from Jason.151

100. Sergeant Cutler recalled that Recruit Kennelly came out to the office and told him Jason was ringing Anatoria’s phone and asked him whether she should answer the phone. He told her that she should.152

101. Recruit Kennelly answered Anatoria’s phone. At this time, Recruit Kennelly said she was still viewing the matter as a potential custody dispute, and her primary concern was that Jason might try to take the children out of the country.153

102. Recruit Kennelly answered the phone and introduced herself. Jason asked her why she was answering his wife’s phone. She responded that she wanted to check on the welfare of the children. He said that he had just got out of the shower and had showered the children and put them in their pyjamas.

Recruit Kennelly said she understood that it would be inconvenient to take the children out again, but that she needed to check that the children were okay. She asked him if he could bring them in to Joondalup Police Station so that she could see them. Recruit Kennelly recalled that Jason seemed calm during the conversation. He did question the need for Recruit Kennelly to check on their welfare, given he was their father, but she explained that it was part of her job and she needed to check on their welfare. Jason told her that he would get the children dressed and be at the station in 20 minutes.

He was casual in his response and the conversation seemed amicable.154 149 T 55; Exhibit 1, Tab 21, p. 39.

150 Exhibit 1, Tab 21, pp. 41 – 42.

151 Exhibit 1, Tab 21, pp. 44 – 46.

152 Exhibit 1, Tab 22, p. 27.

153 Exhibit 1, Tab 21, pp. 47 – 48.

154 T 55 - 56; Exhibit 1, Tab 21, pp. 49 – 50, 57.

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103. Recruit Kennelly explained in her interview with Internal Affairs that she didn’t think he would necessarily be there within 20 minutes, as she was still assuming for some reason that he was in Wanneroo and she understood it might take him some time to organise the children and drive there.155 She did not ask him where he was during the phone call and she later told investigators it didn’t occur to her to ask him, as he seemed so calm and was indicating he would bring the children to the station.156

104. After ending the phone call, Recruit Kennelly said she felt reassured by Jason Headland’s calm and composed manner, but she was still keen to see the children and be satisfied they were okay.157 She spoke to Sergeant Cutler and told him she felt confident that Jason would bring the children in to the station. There was nothing about this conversation that raised Sergeant Cutler’s level of concern as it appeared Jason was compliant and agreeable to bringing the children to the station. At that time he considered there was no reason to disbelieve what Jason had said. Sergeant Cutler also said he was not concerned about the arrangement and thought it was “sound decision making”158 on Recruit Kennelly’s part, as it was an appropriate way of maximising police resources and he could understand that Jason might prefer not to have the police go to his home.159

105. Recruit Kennelly discussed with Sergeant Cutler whether she should put Anatoria and her friend in an interview room or tell her to go home. She explained that she was concerned that if Anatoria stayed at the front counter there might be a confrontation between her and Jason when he arrived.

Sergeant Cutler agreed and suggested that she should send Anatoria home but attempt to get some more details from her before she left.160

106. Sergeant Cutler said he was satisfied with the arrangement and did not consider taking any other course of action at this stage, such as notifying DCC.161 However, Sergeant Cutler conceded in his evidence at the inquest that, in hindsight, the police probably should have got an address from Jason during that conversation, although he did not believe it greatly affected the police response time when a job was later put on.162

107. A/Sergeant Darlington recalled that she rang and spoke to Sergeant Cutler after approximately half an hour to an hour had elapsed and asked him for an update. He told her that they had made some phone calls and the father was coming in to the station with the children. She thought, “Great!”163 and said she was happy with that information.164

108. Recruit Kennelly’s evidence is that she went out to the counter and told Anatoria she had spoken to Jason on the phone and that it would be best if 155 Exhibit 1, Tab 21, pp. 49 - 50.

156 Exhibit 1, Tab 21, pp. 53 – 54.

157 T 56 – 57; Exhibit 1, Tab 21, pp. 50 – 51.

158 T 92.

159 T 57, 91 - 92; Exhibit 1, Tab 22, p. 29.

160 Exhibit 1, Tab 21, pp. 51, 58 - 60.

161 Exhibit 1, Tab 22, pp. 29 - 30.

162 T 91, 96.

163 T 160.

164 Exhibit 1, Tab 23, pp. 16 – 18.

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Anatoria went home, although she could remain at the station in an interview room if she wished. Recruit Kennelly said she gave Anatoria back her phone and told her that she would be in contact with her in an hour.

She gave Anatoria her police number and name and the telephone number for the station, and told Anatoria if she hadn’t heard from her within the hour, she could call her. She then believes she asked Anatoria, who was still accompanied by Katie, if there were any other details she could provide.165 Both Anatoria and Katie said no.

109. Recruit Kennelly said in her interview with Internal Affairs that she asked them, “Anywhere else anybody could be?”166 and Anatoria said, “No.” She then mentioned her car again. She also made some mention at that time to Jason having “problems with mental health”167 and suggested it was due to their relationship breakdown, rather than any history of mental health issues. Katie Cheeseman mentioned at this time that Jason’s brother had previously committed suicide.168 Recruit Kennelly said that this new information did not change her perception of the situation and did not increase her level of concern as she had spoken to Jason by this time and he appeared calm and truthful during the conversation.169

110. Recruit Kennelly acknowledged that she did not tell Anatoria and Katie that Douglas did not have the children with him. She recalled that she told them that she had spoken to Jason and he said the children were fine, and she believes she told them he was bringing them to the station.170

111. Sergeant Cutler accepted he also may not have told Anatoria that Douglas had said the children were not with him. He said there was no reason why he would not have told her, but it was possible he may just not have mentioned it as it wasn’t apparent to him that it was an important factor for Anatoria and Katie.171

112. Anatoria’s evidence was that she always believed that the children were with Jason at Douglas’ house and not at Yanchep, but if she had been told by the police that they were not at Douglas’ house in Wanneroo, her mind would have been directed to Yanchep. However, her understanding when she left the police station was that they were at the house in Wanneroo and the police were going to send someone there to check on the children and then call Antonia to let her know they were okay. She did not recall being asked if they could be somewhere else and Katie also did not recall such a question being asked.172

113. Katie’s evidence was similar to Anatoria’s, in that she recalled they were told, “The kids are fine. They’re all at the house. You can go home, and we will do 165 Exhibit 1, Tab 21, pp. 60 – 61.

166 Exhibit 1, Tab 21, p. 62.

167 Exhibit 1, Tab 21, p. 62.

168 Exhibit 1, Tab 21, p. 62.

169 Exhibit 1, Tab 21, p. 63.

170 T 58 – 62.

171 T 89 - 90.

172 T 20, 23, 36 - 37.

Inquest into the deaths of Zaraiyah-Lily and Andreas HEADLAND (1299 & 1300/2016) 24

a welfare check within the hour and call you.”173 She also assumed this meant that they were with Douglas and Lois.174

114. Anatoria’s recollection of events is supported by a text she sent to Lois as she left the police station. Anatoria apologised to Lois for involving the police and asked Lois to keep the children safe. This is consistent with her evidence that she believed Jason and the children were with their grandparents in Wanneroo.175 Lois confirmed in her evidence that she received the text message asking Lois to “please take care of my babies.”176 Lois said in her evidence this text did give her some cause for concern.177 Katie also recalled that as they left she asked Anatoria if she was happy with the outcome and Anatoria said to her, “Yes. If they’re with Doug and Lois I know they’ll be safe.”178 On that basis, they were happy to leave.179

115. Both Anatoria and Katie gave evidence that they were unaware of the arrangement for Jason to bring the children to the station. They believed the police were going to go and check on them at Douglas and Lois’ house.180 Katie gave evidence that she would have been concerned that it was “buying him time”181 and she believes she “would have put up more of a fight and said, “No. You just need to go there now. You need to go and find him.”182

116. Anatoria, on the other hand, indicated she would not have been overly concerned if she had been aware that Jason would be coming in, other than wishing to avoid contact with him herself. However, Anatoria made it clear that she truly believed that the children were with their grandparents as well as Jason, and this was an important fact in her mind as she knew Doug and Lois would keep them safe. She said that if she had known they were just with Jason, it would have changed how she felt as she didn’t want them alone with him after receiving that phone call from him.183

117. Anatoria and Katie left the station and Recruit Kennelly began to deal with a man at the counter who was in an agitated state.184 While speaking to this person, Recruit Kennelly said she kept an eye on the doors in anticipation of Jason’s arrival.

118. Sergeant Cutler went back to his office and he recalled that at some stage he conducted a thorough check on the police computer system and found no domestic violence history and no adverse incident recorded between Anatoria and Jason. He noted the address for both Anatoria and Jason was recorded as the Wanneroo address.185 Sergeant Cutler said he looked up to check the

173 T 22.

174 T 22.

175 T 38.

176 T 143.

177 T 143.

178 T 24.

179 T 24 – 25.

180 T 24, 37.

181 T 24.

182 T 24.

183 T 43.

184 Exhibit 1, Tab 21, pp. 64 – 65.

185 Exhibit 1, Tab 22, p. 33 – 34.

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monitor as people came in, to see if a male with two children entered, but didn’t see anyone matching that description.186

119. Jason continued to try to call Anatoria numerous times despite her sending him a text telling him not to call her.187 He did not, however, answer his father’s calls, or later calls from the police. He also did not bring the children to the police station nor to his parents, as promised.

120. After approximately 40 minutes had elapsed Recruit Kennelly concluded her dealings with the man and turned her attention to Jason Headland’s whereabouts. She said she was concerned and was thinking “Where are these children?”188 Recruit Kennelly went into the office and spoke to Sergeant Cutler and told him that Jason had not arrived and “something doesn’t feel right.”189 Sergeant Cutler recalled approximately 45 minutes to one hour had elapsed by this time and it was apparent Recruit Kennelly was not comfortable with the amount of time that had elapsed with no sign of Jason.190

121. Recruit Kennelly recalled that she asked Sergeant Cutler if he thought she should contact Jason, and Sergeant Cutler said that she should. Recruit Kennelly then attempted to telephone Jason Headland a number of times, but he did not answer the phone and the calls went to message bank. She did not leave a message, but continued to try to call him.191

122. Recruit Kennelly considered it was possible he was not answering the phone because he was driving, or alternatively his failure to answer could be because he was trying to evade her. After failing to contact Jason, Recruit Kennelly took the next step of calling Jason’s father, Douglas Headland, again. On this occasion, Douglas answered the phone. Recruit Kennelly asked him if he had spoken to Jason, and Douglas said no and he told her that he couldn’t get hold of Jason.192

123. Recruit Kennelly said that her “concerns were escalating”193 at this stage, but still only to the extent that she thought he might have run away with the children, rather than any thought that he might have caused them harm.

She gave evidence that at this stage, she was thinking, “I want to know where these kids are.”194

124. Recruit Kennelly decided to call Anatoria to see if Jason had changed his mind and decided to go and see her instead. She rang Anatoria, who had been waiting anxiously for the call,195 and asked if there was anywhere else that Jason could possibly go. It was at this time that Anatoria mentioned their house in Yanchep for the first time.196 186 Exhibit 1, Tab 22, pp. 35 – 36.

187 Exhibit 1, Tab 24B, pp. 6 – 7.

188 Exhibit 1, Tab 21, p. 68.

189 Exhibit 1, Tab 21, p. 72.

190 Exhibit 1, Tab 22, p. 36.

191 Exhibit 1, Tab 21, pp. 74 – 75.

192 T 64; Exhibit 1, Tab 21, p. 78.

193 Exhibit 1, Tab 21, p. 78.

194 T 66.

195 T 38.

196 Exhibit 1, Tab 21, p. 79.

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125. Recruit Kennelly said she was a little shocked that she hadn’t already been given this information and she immediately obtained the address from Anatoria. Anatoria, on the other hand, said she felt lost at the question because it had never occurred to her he could be in Yanchep. When she came off the phone, she told Katie about the question of another address.

Katie was also shocked and confused but they decided he must have travelled to Yanchep later.197

126. Recruit Kennelly asked Anatoria if she had spoken to Jason, and she said he had not stopped calling her, but she had not answered his calls and did not want to speak to him. Anatoria seemed calm but annoyed that Jason wouldn’t stop calling her.198

127. Recruit Kennelly told Internal Affairs investigators that she had a “gut feeling”199 at this stage. She didn’t say anything about her concerns as she didn’t want to scare Anatoria, so she simply told Anatoria that she would call her back shortly and ended the call.200 Recruit Kennelly said that after this call she “wanted to get a car out there to check on the kids.”201 Her concerns were escalating, although her concerns were still focussed around Jason taking the children away somewhere, rather than any fear that he would physically harm them.202

128. Recruit Kennelly said her next step was to put a job on the police computer system. She couldn’t recall if she spoke to anyone before doing this, although Sergeant Cutler recalled that she came to see him and told him that she had called Jason a couple of times and he was not answering his phone, and they then agreed “that a job should go on for police to attend the house”203 and they should send a car out.204 Sergeant Cutler indicated he did not think it was an emergency situation but it appeared that the father was not being as cooperative as originally anticipated and police needed to follow it up.205

129. Sergeant Cutler was not sure when he became aware of the Yanchep address, but thought it might have been when Recruit Kennelly went to log the job. He said he had not thought about trying to get a triangulation on Jason’s phone, to identify his whereabouts, prior to police obtaining this address, as there was no definite threat to any person at that time.206 Despite the words Jason had used when speaking to Anatoria, Sergeant Cutler said he did not think he was planning to hurt the children and didn’t consider the words represented a genuine threat to harm them.207

197 T 25, 39.

198 Exhibit 1, Tab 21, p. 82.

199 Exhibit 1, Tab 21, p. 80.

200 Exhibit 1, Tab 21, pp. 83 - 84.

201 T 67.

202 T 69.

203 Exhibit 1, Tab 22, p. 36.

204 T 92, 94.

205 Exhibit 1, Tab 22, p. 37.

206 Exhibit 1, Tab 22, p. 41.

207 Exhibit 1, Tab 22, p. 38, 42.

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130. Sergeant Cutler recalled that he suggested to Recruit Kennelly the job code that she then entered and he understood it would be a priority 3.208 He did not consider it should be a priority 2 or higher at that time, as he did not think there was any evidence of an imminent threat.209

131. The CAD job was logged at 9.18 pm. Recruit Kennelly designated the job with the job code 348, which is a priority 3 welfare check.210 Recruit Kennelly was new to the job system, and she indicated that she “kind of expected something to happen pretty sharpish”211 in response to the job being created. Recruit Kennelly also believed she generally was not permitted as a recruit to put on a job above Priority 3 level, but the DCC could increase the priority if they deemed it necessary after reading the job.212

132. However, according to the police priority system, a Priority 3 is only required to be attended to within one hour. Sergeant Cutler understood this to be the case, and felt that was a reasonable time period in the circumstances as they were known at the time.213

133. Around this time, at about 9.05 pm, Douglas rang Sergeant Cutler. Lois gave evidence that she had told him to make the call after Jason had not arrived, as she wanted Douglas to give the police the Yanchep address. She understood Douglas gave them the address and they left it at that. Douglas explained at the inquest that when Jason had not turned up he had begun calling him, but Jason did not answer the calls, which he thought was unusual (although I note Lois said he did sometimes not answer calls when he was a little bit angry and upset about something).214 Douglas agreed that he and Lois could have driven out to the Yanchep house, but they were not that concerned at that stage. It was more the case that they were trying to work out what was going on.215

134. Douglas told Sergeant Cutler that he wanted to be advised when the police located the children. Sergeant Cutler could not recall whether Douglas provided the Yanchep home address at this stage, although he was aware police had already obtained the address from Anatoria.216 Lois’ evidence suggests Douglas did give the police the address at this time.

135. Sergeant Cutler said he did not consider the call from the children’s grandfather changed the situation to one requiring an ‘emergency type’ response although he acknowledged it raised his level of concern slightly.

However, he assumed Jason may have turned off his phone. Sergeant Cutler did not take any action as a result of Douglas Headland’s phone call.217 I note that Lois’ evidence was that they “did not think anything more of it”218 after that call to the police and they went to bed, which is consistent with 208 Exhibit 1, Tab 22, p. 40.

209 T 96 – 97; Exhibit 1, Tab 22, p. 41.

210 Exhibit 1, Tab 21, pp. 84 – 87.

211 Exhibit 1, Tab 21, p. 90.

212 T 68 - 69.

213 Exhibit 1, Tab 22, pp. 45 – 46.

214 T 148.

215 T 134 - 135.

216 Exhibit 1, Tab 22, pp. 42 – 43.

217 T 97, 102; Exhibit 1, Tab 22, pp. 43 – 44.

218 Exhibit 2, Tab 4 [86].

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Sergeant Cutler’s evidence that Douglas was not conveying any high level of concern. When Lois and Douglas were later woken up by police and informed of what had occurred, it was their “worst nightmare,”219 and clearly not something they had ever contemplated when they retired to bed that night. If anything, it seems they had been more worried Jason might hurt himself.220

136. Shortly after the job was created, Senior Constable Holman from the DCC came out and spoke to Recruit Kennelly. She recalled he asked her for phone numbers and also asked her for the address and to tell him what was going on. She said she told him that she had concerns for the children.221 Recruit Kennelly indicated she still did not consider this to be a ‘life and death situation’ and did not have any suspicion the children might be hurt, based upon what she knew, she just wanted the children to be sighted.222

137. A/Sergeant Darlington recalled that Senior Constable Holman went out to speak to Recruit Kennelly as there was an issue with the address because only the Wanneroo address came up and it was known that Jason Headland was not at that address. He went out to get further addresses and then soon after, at 9.20 pm, added in the address at 10 Flight Vista, Yanchep. This was highlighted at 9.30 pm.223 In the meantime, Recruit Kennelly got called to attend to another job on the front counter and Sergeant Cutler went about his other duties, with the expectation that the job would be allocated in due course.

138. A mental health officer had also vetted the job to confirm that Jason had no documented mental health history that might be relevant or attending police might need to know about.224

139. At the time the job was updated with the proper address and highlighted at 9.30 pm, the only available car was a detectives’ vehicle. It would not ordinarily be used for a 348 job and was not dispatched in this case. The job was eventually dispatched to a North West Metro Response police vehicle at 9.50 pm.225

POLICE ATTENDANCE AT THE YANCHEP HOUSE

140. The police car arrived at the house at 10.17 pm after travelling at the speed limit given they were not under emergency priority. The house was dark and silent when they arrived. The police officers knocked on the front door but received no answer. The police officers then walked around the house and looked in the windows. One officer looked into the main bedroom and saw Jason lying bleeding on the ground with a knife by his head.226

219 T 149.

220 T 149.

221 Exhibit 1, Tab 21, pp. 93 – 94.

222 Exhibit 1, Tab 21, pp 97 - 98.

223 Exhibit 1, Tab 22, pp. 22 - 23.

224 T 162 - 163.

225 T 162; Exhibit 1, Tab 23, pp. 24 – 27.

226 Exhibit 1, Tab 24B, p. 7.

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141. Based upon what they had seen, the police officers broke in to the house and made their way immediately to the main bedroom. They found Jason on the floor and Zaraiyah-Lily and Andreas lying on the bed. They checked both children but neither of them had a pulse and it was clear they had died.

Jason was alive but unresponsive. He had stab wounds to his neck and superficial injuries to his wrist. A number of knives and a bottle of alcohol were near him. There was also a large quantity of blood.

142. The police requested the attendance of paramedics. The first crew arrived at 10.38 pm. While waiting, the police officers had provided first aid to Jason’s neck wounds. It was apparent he had lost a lot of blood but he still had a heartbeat. The paramedics took over his medical treatment and he was taken by ambulance to hospital for treatment. A paramedic checked Zaraiyah-Lily and Andreas and confirmed that they had both died. They both showed signs of rigor mortis and lividity, suggesting they could have been dead for some time. It was not an option to attempt to resuscitate them given the time that had elapsed.227

143. Police found children’s cups in the house that appeared to contain juice and crushed tablets and a partially empty packet of Restavit (the active ingredient being doxylamine). The packet is sold as 20 x 25mg tablets and 12 tablets were missing.228

144. The learned sentencing Judge was satisfied Jason purchased the Restavit with the intention of using it to drug and then kill the children.229 Her Honour was also satisfied that Jason lied to his father and stepmother and the police to buy him some time to put his plan to kill the children into effect. Jason had the children drink some juice containing crushed Restavit tablets, thereby sedating them, and sometime after 8.00 pm he asphyxiated both children. The children died as a result of his actions, although it is not known the exact manner in which he asphyxiated them, exactly when he did so, how long it took for them to die or their time of death.230

145. Jason had written a note and put it at the bottom of the bed. The note made it clear that Jason had killed the children. The learned sentencing Judge described it as a “very callous, shallow and self-centred note.”231 In the note, Jason indicated he had chosen to kill Zaraiyah-Lily and Andreas to punish Anatoria for her decision to end their relationship. He professed his love for Zaraiyah-Lily and Andreas, but it is clear that his actions were prompted by hatred, selfishness and vindictiveness and he had no regard for the welfare of his children. Any previous description of him as a loving father was undone forever at the moment he coldly and cruelly took their lives.232 227 Exhibit 1, Tab 16.

228 Exhibit 1, Tab 24A, p. 7.

229 Exhibit 1, Tab 24B, p. 5.

230 Exhibit 1, Tab 24B, p. 7.

231 Exhibit 1, Tab 24B, p. 8.

232 Exhibit 1, Tab 24A, pp. 6 – 7; Tab 24B, p. 10, 12.

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CAUSE OF DEATH

146. Forensic Pathologist, Dr Vicki Kueppers, performed a post mortem examination on the bodies of Zaraiyah-Lily and Andreas. The post mortem findings were similar in both cases.233

147. No abnormalities were detected and there was no evidence of significant natural disease in either child that would have accounted for death. There was some iron deposition consistent with Andreas’ medical history of a type of congenital anaemia, but this was not considered to be contributory to his death in any way.234 Further, no injuries were found that would explain their deaths, although there were findings that caused Dr Kueppers to become suspicious that pressure had been applied to the neck and/or chest of both children, which I will come to later.235

148. Significant findings also came from toxicology analysis, so an expert opinion was obtained from Professor David Joyce. Professor Joyce is a Physician, Clinical Pharmacologist and Toxicologist who regularly provides expert opinions in coronial matters on the relationship between drugs detected in the post-mortem examination and the cause of death. Professor Joyce provided such an opinion in relation to the deaths of Zaraiyah-Lily and Andreas. The results and conclusions were effectively identical for both children.236

149. Both children showed tablet residue in their stomachs and the drug doxylamine was detected within the stomach contents and in the blood sample results, consistent with the children being given the Restavit tablets Jason purchased that day.237

150. Professor Joyce explained doxylamine is an old antihistamine drug that has largely been superseded as a treatment for that condition, in large part because it had the undesirable consequence of a very sedating effect.

Because of that effect, it now continues to have a use as a mild sedative.238

151. Professor Joyce indicated that, when taken in conventional therapeutic doses, the drug is pretty safe, but when taken in excessive doses it can oversedate to the point of putting people into deep coma to the point they stop breathing or are unconscious and unable to protect their airways from aspirating vomit (although that did not occur in this case).239 Children are particularly sensitive to the sedating effects of the drug, and they are also susceptible to what is described as its ‘muscarinic effect’. The ‘muscarinic effect’ is said to be similar to the effect of deadly nightshade, including epileptic seizures and confusion and disturbance of the heart rhythm potentially leading to cardiac arrest. Due to their susceptibility, children are 233 Exhibit 1, Tab 5.

234 T 125.

235 T 122; Exhibit 1, Tab 5.

236 Exhibit 1, Tab 8 and Tab 17.

237 Exhibit 1, Tab 5.

238 T 113 – 114.

239 Exhibit 1, Tab 5.

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at increased risk of serious poisoning and death, so doxylamine is contraindicated for use in children under 12 years of age.240

152. Allowing for post-mortem redistribution and the fact the specimens were whole blood specimens, rather than concentrations in serum or plasma, Professor Joyce was able to comment that the concentrations found in both children were about seven or eight times higher than might occur in an adult who had taken a conventional dose. The comparisons are made with adults as there is no specific data for children because the drug is never part of normal therapy for children.241 In comparison, Jason’s blood indicated he had taken a conventional dose.242

153. Although much higher than an ordinary adult dose, looking at the concentrations, Professor Joyce was able to say that they would not conventionally be associated with death from doxylamine poisoning, and were at least 20 times lower than reported fatal concentrations. Therefore, Professor Joyce concluded that the drug, on its own should not have caused their deaths. However, the children would have been suffering from overdose and would have been experiencing the consequences of an overdose and they required medical treatment.243

154. Professor Joyce indicated the children would definitely have been sedated, probably to the extent that they would have been fairly deeply sedated and be pretty difficult to rouse from sleep. This would have left them insensible and unable to protect themselves against a violent attack. In addition, the confusing effects of the muscarinic action would have made the children much less capable of making sense of what was happening and be able to escape, if lethal violence was perpetrated upon them.244

155. In that context, it is relevant that the post-mortem examination found florid petechial haemorrhages (pinpoint blood spots) to the head of both children.

Zaraiyah-Lily’s examination also showed superficial markings (faint apparent bruising) over the front of her neck. These were the findings that made Dr Kueppers suspicious that force had been applied as the findings are consistent with asphyxiation. Dr Kueppers noted that the florid petechiae to the heads of both children remain unexplained and was highly suspicious of mechanical asphyxiation, meaning pressure having been applied to the neck and/or chest. The findings of bruising around Zaraiyah-Lily’s neck were also consistent with such a conclusion. The fact that the deceased were both children, and very likely heavily sedated, also meant that little or no resistance would have occurred, so the lack of other injury was not surprising as they were unlikely to have provided any resistance.245

156. Taking into account all of the post mortem examination findings, and after considering Professor Joyce’s opinion about the sedating effect of the doxylamine, Dr Kueppers was unable to definitely say what caused 240 T 114 - 115; Exhibit 1, Tab 8, p. 2.

241 T 116 – 117; Exhibit 1, Tab 8 and Tab 17.

242 Exhibit 1, Tab 24A, pp. 7 – 8.

243 T 116 – 117; Exhibit 1, Tab 8 and Tab 17.

244 T 118; Exhibit 1, Tab 5, Tab 8 and Tab 17.

245 T 123; Exhibit 1, Tab 5.

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Zaraiyah-Lily and Andreas’ deaths. Therefore, the causes of death for both children were unascertained. However, Dr Kueppers indicated in her opinion, while unascertained, the deaths were consistent with asphyxiation in a child with drug effect and she considered this to be the most likely explanation based upon all the information available to her.246 Professor Joyce indicated his general agreement with this opinion.247

157. No further information about the cause of death was able to be gained from the perpetrator, as Jason claimed he had no memory of how he killed them.248

158. Based upon all the evidence before me, including specifically the opinions of Dr Kueppers and Professor Joyce and Jason Headland’s admission that he caused the deaths although he has not disclosed the manner in which he did so, I am satisfied that the cause of death for both Zaraiyah-Lily and Andreas is asphyxiation in a child with drug effect.

MANNER OF DEATH

159. Jason had some self-inflicted neck injuries when he was found by police at the time the children’s bodies were discovered, but he fully recovered from his injuries after medical treatment. On 21 October 2016 he was charged with the murders of Zaraiyah-Lily and Andreas. He maintained he did not recall how the children died, but admitted causing their deaths. He pleaded guilty to both charges on 29 March 2017 and was remanded in custody for sentencing.249

160. On 27 July 2017 Jason Headland was sentenced by her Honour Justice Jenkins in the Supreme Court of Western Australia to life imprisonment with a non-parole period of 31 years’.250

161. Following the conviction in the Supreme Court, I find that the manner of death in relation to both Zaraiyah-Lily and Andreas is by way of unlawful homicide.

COMMENTS ON POLICE CONDUCT

162. The person who caused the deaths has been held to account in another court, superior to this one, and he now serves the sentence of life imprisonment imposed for his crimes. My task is different in looking at whether anyone else caused or contributed to the death, with a focus more towards future death prevention than any apportionment of blame. However, as part of the task, I must consider whether the police officers could, or should, have done more on the night to potentially prevent these deaths.

From consideration of that question we hopefully learn ways to intervene 246 Exhibit 1, Tab 5.

247 T 119.

248 Exhibit 1, Tab 24A, pp. 21 - 23; Tab 24B, p. 13.

249 Exhibit 1, Tab 20.

250 Exhibit 1, Tab 20.

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and prevent future deaths. For sadly, although we would like to think these things never happen, experience even in very recent years in Western Australia has taught us that some people in the face of a marriage breakdown or other life pressures will take the coward’s way out and children and family needlessly die as a result.

163. The evidence before me indicates that no one realised that Jason Headland was capable of hurting his children until it was too late. At worst, they thought he might steal the children away somewhere. Anatoria said in her evidence that she had “complete faith”251 in Jason that he would not harm their children, right up until the very point that she found out what he had done. Instinctively on that day she “just thought something was wrong” and wanted to check that they were okay, but she could not explain it as anything more than gut instinct. Her concern certainly did not arise from a belief that he might hurt Zaraiyah-Lily and Andreas and she agreed that she would not have conveyed such a concern to the police. She just wanted to be reassured they were safe, without really knowing why. Sadly, her mother’s instinct that something was wrong proved to be correct.252

164. Lois gave evidence that she spoke to Anatoria after these events, and Anatoria expressed to her feelings of frustration at the fact that she was not taken seriously at the Joondalup Police Station.253 It is entirely understandable that she would feel this way, given what occurred. The police evidence is that Anatoria was not conveying any great distress at the time, but I have no doubt that internally she was very anxious and concerned. The manner in which Anatoria gave her evidence in court, where she appeared outwardly calm although, I am certain she was extremely nervous and upset throughout, shows that she is good at maintaining her composure under great stress. Unfortunately, her level of composure led police to underestimate her level of concern. In addition, she had not allowed herself to contemplate the worst case scenario.

165. Police officers know more than the average person about the terrible acts that human beings are capable of, and they take this knowledge and their experience into account when considering the reports made to them by members of the public. Therefore, although Anatoria and Katie did not convey a belief they thought Jason was intending to physically harm the children, the police officers (and recruit) involved in taking their report had to put it in the context of what might be the worst case scenario in this situation. On the other hand, there was evidence that these types of requests for welfare checks are common, and almost all of them are resolved with a positive outcome.

166. In considering whether other steps could have been taken, I asked the police officers involved, and the police officer who reviewed their conduct afterwards, whether they felt that there were actions that in hindsight could, or should have been taken.

251 T 42.

252 T 42 - 43.

253 T 149.

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167. As part of the WA Police investigation, an officer from the Internal Affairs Unit looked into the agency’s response, starting from the initial contact with Anatoria and Katie at the Joondalup Police Station, to consider the actions of the officers involved and to determine whether they acted appropriately and in compliance with WA Police policies, procedures and regulations. Detective Senior Sergeant Brad Pinch was in charge of the investigation and he prepared a report that was tendered at the inquest.254

168. Detective Senior Sergeant Pinch interviewed the officers involved and some of the relevant materials, although he did not review the full criminal prosecution brief.255 He considered whether Recruit Kennelly, Sergeant Cutler and A/Sergeant Darlington failed to act appropriately to Anatoria’s report of welfare concerns. He found that there was no information provided to the police at the time to elevate their concerns and the response of the officers was appropriate and reasonable.256 Detective Senior Sergeant Pinch did find that, in hindsight, it would have been beneficial if Recruit Kennelly had asked Jason for details of his location when she had a telephone conversation with him.257 Detective Senior Sergeant Pinch also agreed in questioning that it could have been helpful for a CAD job to be started at an earlier stage, although he noted there was a vacuum of information and later an alternative way of dealing with the problem presented itself.258

169. The alternative way was, of course, Jason agreeing to come into the station.

Detective Senior Sergeant Pinch agreed that it was an unusual approach and it carried some risk, but based on the information the police officers had at the time, he did not consider it to be inappropriate. The level of concern increased when he did not present, as arranged, and Detective Senior Sergeant Pinch believed the officers were suitably proactive from that time.259

170. Recruit Kennelly, who has now graduated and is a police constable, said throughout her evidence that she had a ‘bad feeling’ from the moment that Anatoria and Katie came to the front desk and made their report. It is clear that she was disturbed that young children were involved and she wanted to check on the welfare of the children, which prompted her to immediately involve her Sergeant and then go to the DCC with him. Despite what Sergeant Cutler said at the inquest about why he went to the DCC, my impression of his actions and conversations on the day in question is that they also indicate he was sufficiently concerned to take the unusual course of going personally to the DCC to seek some advice, with the possibility that they might be able to send a car out immediately.260

171. However, after speaking with A/Sergeant Darlington, they altered their course and began to make some further enquiries. The later internal investigation found that she was correct in identifying that their request to put on a job came somewhat prematurely and the scant initial details were 254 T 166; Exhibit 1, Tab 19.

255 T 167; Exhibit 1, Tabs 21 – 23.

256 T 167 – 168; Exhibit 1, Tab 19.

257 Exhibit 1, Tab 19, p. 34.

258 T 170, 174.

259 T 170, 174.

260 T 77.

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not sufficient to enable a CAD task to be placed onto the system.261 When they went away and made some calls, the arrangement was made for Jason to come into the station, which all the police officers involved felt was an appropriate solution.

172. Recruit Kennelly was asked at the inquest whether, having reflected on these events and with the benefit of hindsight, she felt she could or would have done anything differently? Her answer was, “No,”262 based upon the information she knew at the time. She agreed that if she had known then all of the information she knew at the time of the inquest, that information would have changed the nature of the job, and the decisions she made.

However, Recruit Kennelly said that she believes at the time she was getting as much information as she could to get the job initiated.263

173. Sergeant Cutler gave evidence that, based on what they knew at the time, he was “comfortable … in what we did.”264 Sergeant Cutler indicated that police welfare check requests where parents have separated are not uncommon, and would be in the order of at least one request a week. Most of them are resolved with the children found to be safe and well, so the outcome in this case was extremely rare and unexpected. Even looking back in hindsight, Sergeant Cutler did not feel that there was information available that might have predicted this terrible outcome. Further, Sergeant Cutler said he would approach a similar situation in the same way now.265 Sergeant Cutler did, however, concede in his evidence that it would have been better to get an address for Jason when Recruit Kennelly spoke to him, as the internal investigation found.

174. A/Sergeant Darlington commented in her interview with Internal Affairs investigators that they deal with these sorts of welfare requests on a daily basis and this case was dealt with in the same way they ordinarily would. At the time, based upon what she knew, a 348 classification was an appropriate job code as it did not appear to require an urgent response.266 At the inquest, when asked if anything different could have been done, she responded, “I think as tragic as the outcome is, we acted correctly. We followed protocol and we did everything we could.”267 She emphasised that the police involved needed to look at the bigger picture, rather than just the words Jason had said to Anatoria, and it was important to get as much information as possible to assess the situation. A/Sergeant Darlington also said that with the number of welfare 348 jobs that the WA Police get daily, there must be a level of scrutiny of each job to look for pre-indicators that might heighten the priority of a particular job, and deal with each case on its merit.268

175. The general conclusion was that, although Jason had made some very concerning statements to Anatoria, even Anatoria and Jason’s father and 261 Exhibit 1, Tab 19, p. 32.

262 T 70.

263 T 75.

264 T 100.

265 T 105 – 109.

266 Exhibit 1, Tab 23, p. 29.

267 T 164.

268 T 164 – 165.

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stepmother did not consider those statements might suggest he presented a real threat to the children, and so the officers took their sense of urgency and level of concern from them.269 I must admit that I find it surprising that none of the officers felt in hindsight they could or should have done anything differently, particularly given Lois’ admission they have plagued themselves with thoughts of what they might have done differently. I can understand that in many ways they do not want to consider an alternative scenario that might have changed the course of events, and the burden that would carry, but I can’t help wondering whether things might have been different if Recruit Kennelly in particular, as she had the strongest instinctive sense of concern, had been allowed to rely more on her gut instinct.

176. When I say things might have been different, I am not suggesting that the deaths would definitely have been averted, as it is clear Jason had formulated a plan from at least early afternoon, and was intent on putting that plan into effect. If police had attended earlier, he may have taken more drastic action to carry out his intent. Further, it is unknown at what time the children died, other than the learned sentencing judge found they were asphyxiated sometime after 8.00 pm. The police report was not made until around 7.00 pm, so without something to indicate extreme urgency, which there was not in this case, it is unlikely police would have arrived any earlier than 8.00 pm even if a CAD job had been created at the start. However, from the police perspective, it would certainly be reassuring to know that everything possible was done to get there quickly. Ultimately, it can’t be put higher than a possible missed opportunity for police to make face to face contact with Jason at an earlier stage, with the hope that it might have deterred him from the path that he was set upon that night.

177. In that sense, I raised with Detective Senior Sergeant Pinch the lack of urgency when Jason had not arrived, as planned, and Douglas had also rung up Sergeant Cutler to convey some level of concern. In my opinion, any reassurance that might have been taken from Jason’s apparent willingness to present to the station must have dissipated by then. Detective Senior Sergeant Pinch agreed that it would have been more prudent to send a vehicle earlier, but he still considered that the level of urgency had not increased by that stage to the point that it suggested that resources should be taken from another job.270

178. Detective Senior Sergeant Pinch also agreed that, with the benefit of hindsight, there was potentially more information available that could have increased the level of urgency, such as the information about the security incident at PMH earlier in the year. His focus was upon the availability of that type of information from electronic resources, in the sense of a more global government information system. In my mind, a simpler answer is the police officers could have considered taking Anatoria and Katie to a quieter place to discuss any concerns, given the nature of her report indicated there was the potential for domestic violence issues to arise. She may have felt more comfortable discussing that kind of information away from the general public. Knowing what we know today about domestic violence and the

269 T 175 – 176.

270 T 177 – 178.

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breakdown of marriages often being a trigger point for an escalation, I see some benefit in police officers taking more time to try to get information in such a case, preferably in an environment that is conducive to creating a sense of safety and confidence.271

179. Interestingly, it was also clarified in questioning that if Anatoria had called in her welfare request, rather than coming in to the station, it is likely it would have led to a job being started at that early stage, although potentially the car would have been sent to Wanneroo in the first instance, and it would then depend on whether Douglas and Lois felt comfortable at the time to disclose Jason’s address.272

180. In the end, I am left with a feeling of disquiet, as the police recruit who took the initial report had a very strong, instinctive feeling that something was amiss, and it was through the advice of her superiors, and following police procedures, that she was directed to take a less direct path to checking on the children’s welfare. Checks on the police system did not find a previous history that would raise an alert. However, domestic violence is a very real part of today’s society, and we know that often the victim’s do not come forward for many years, until things reach a crisis point. There will not always be a documented history of such behaviour, as is shown in this case.

Further questioning of Anatoria would probably have revealed information that would have changed the picture.

181. I understand that every situation is different, but I believe this case reinforces the need for police officers to trust their instincts more, particularly where vulnerable children are involved. Sadly, there have been too many recent cases where men have killed family members without warning, so any opportunity to intervene must be taken seriously. I know that these cases are rare, but the consequences are so great that I think it should be at the back of every police officer’s mind when being asked to conduct a welfare check on a child.

CONCLUSION

182. At the sentencing hearing, a victim impact statement written by Anatoria was read to the court. As the learned sentencing Judge described it, Anatoria poignantly and beautifully described Zaraiyah-Lily’s and Andreas’ personalities, her hopes and dreams for them and her love for them.”273 Anatoria described Zaraiyah-Lily and Andreas as “bubbly and happy children with the world at their feet.”274 They loved each other and their family and they in turn were adored by their family and friends. ZaraiyahLily loved to dress up and sing and dance. She was also clever and loved to cook. Andreas would play instruments while his sister sang and danced around him. His favourite thing in the world was his Winnie the Pooh bear, which was with him always. They were already little people, with their own

271 T 182 - 184.

272 T 185 – 186.

273 Exhibit 1, Tab 24B, p. 10.

274 Exhibit 1, Tab 24A, p. 8.

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talents and personalities, but they will never be able to grow up to be the amazing adults they were destined to become.275

183. Every coronial case carries with it some sadness, but the deaths of ZaraiyahLily and Andreas stand out as two of the worst I have dealt with in this jurisdiction. That they died at the hands of their father, who betrayed their trust and the trust of their extended family for the most selfish of reasons, demonstrates everything that is opposite to what we expect in a parent.

Jason told Anatoria that he would break her heart into a million pieces, but it was clear that he broke many more hearts than hers. Anatoria pointed out at the sentencing that he also broke his family’s hearts and those of his friends.276 It was apparent at the inquest that all of the police officers involved were also devastated by the deaths. A/Sergeant Darlington spoke on behalf of herself, Sergeant Cutler and Recruit Kennelly and offered their deepest sympathy to Anatoria for the loss of her beautiful children and indicated that they also carry the burden of the children’s loss every day.277 No one involved in this inquest was unaffected by this tragedy and I am sure every member of the community who heard about it was deeply saddened.

184. Although many families suffer turmoil during marriage breakdowns, it is thankfully a rare case that ends in tragedy like this. However, it is not so rare that it can be assumed it won’t happen again. Looking forward, it is very difficult to make any sweeping recommendations that might avert such a tragedy in the future. What I hope can come from this inquest is a better understanding on behalf of families and police officers that people can be unpredictable when they are under severe personal stress, and it is always important to remember these isolated but extreme cases when considering how to respond to people behaving out of character.

185. In Jason’s case, no one could believe he would harm his beautiful children, based upon his past history as a son, husband and father, and yet he took that step deliberately and callously to exact revenge on his wife. His wife, whilst not fully able to believe what he might be capable of, knew enough instinctively to ask the police for help. Whilst I understand there is always a need to consider each case on its merits, and there is a finite limit to police resources at any given time, I encourage every police officer to remember these deaths when considering how to prioritise welfare checks on children during a marriage breakdown.

S H Linton Coroner 16 January 2020 275 Exhibit 1, Tab 24A, p. 8.

276 Exhibit 1, Tab 24A, p. 10.

277 T 165 – 166.

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