Deceased
Davide Candeloro
Demographics
48y, male
Coroner
Deputy State Coroner Linton
Date of death
2019-07-03
Finding date
2021-04-20
Cause of death
Severe soft tissue injury to the left arm, consistent with impact with a wire fence during a high-speed motorcycle crash
AI-generated summary
Davide Candeloro, 48, died from severe laceration to his left arm after his Harley Davidson motorcycle crashed into a wire fence at high speed on a residential street. Police officers had initiated a brief traffic intercept after observing what they believed was excessive acceleration. Mr Candeloro failed to stop, accelerated away, and police immediately disengaged for safety reasons, turning off lights and siren and reducing speed. Mr Candeloro continued riding at approximately twice the speed limit (85-102 km/h in a 50 km/h zone), failed to negotiate a bend, and crashed. Toxicology revealed methylamphetamine in his system. The coroner found police conduct complied with policy, with appropriate risk assessment and timely disengagement. The fatal arm injury would have required tourniquet application within 2-3 minutes; evidence suggests this window had likely passed before police discovered the crash. No police responsibility for the death was established.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Drugs involved
[2021] WACOR 13 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON, DEPUTY STATE CORONER HEARD : 16 DECEMBER 2020 DELIVERED : 20 APRIL 2021 FILE NO/S : CORC 921 of 2019
DECEASED : CANDELORO, DAVIDE Catchwords: Nil Legislation: Nil Counsel Appearing: Mr W Stops assisted the Coroner.
Ms S Smith with Mr J Dawson (SSO) appeared on behalf of the WA Police Force.
Case(s) referred to in decision(s): Nil
[2021] WACOR 13 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Deputy State Coroner, having investigated the death of Davide CANDELORO with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, PERTH, on 16 December 2020, find that the identity of the deceased person was Davide CANDELORO and that death occurred on 3 July 2019 at Peel Health Campus, 110 Lakes Road, Mandurah, from injury to the left arm in the following circumstances:
TABLE OF CONTENTS SUPPRESSION ORDER On the basis it would be contrary to the public interest, I make an order that there be no reporting or publication of the details of any of the versions of the WA Police Emergency Driving Policy and Guidelines, including, but not limited to, any cap on the speed at which police officers are authorised to drive.
Davide Candeloro (Mr Candeloro) died on 3 July 2019 from injuries he suffered when the motorcycle he was riding left the roadway on Orestes Street in San Remo and crashed at speed into a wire fence in the sand dunes.
Immediately prior to his death, Mr Candeloro had been seen riding his motorcycle by two police officers who were on patrol in the area. They believed he was riding at speeds above the speed limit and they had activated their lights and siren in an attempt to pull him over and speak to him. Mr Candeloro failed to stop and accelerated away from the police. They followed him with their lights and siren on for a short time before deciding it was too dangerous to continue attempting to stop the motorcycle. They gave evidence they then turned off their lights and siren and returned to normal patrol speed. They did, however, continue in the same direction as Mr Candeloro.
There is objective evidence, in the form of CCTV footage, to show that Mr Candeloro’s motorcycle failed to negotiate a left hand bend on Orestes Street, left the road, mounted the verge and crashed into a fence in the sand dunes at about 9.30 pm. The police drove past a short time after, but the police officers said they didn’t see the crashed motorcycle because it was dark. People in nearby houses had heard the crash and came out to see if they could help. The footage shows they emerge after the police car has passed. A short time later the police car had turned around to follow another car and drove back past the crash scene. The police officers saw the people and then realised the motorcycle had crashed. They stopped to assist and provided some first aid to Mr Candeloro until an ambulance arrived and took Mr Candeloro to hospital. Unfortunately, he died at the hospital.
Due to the police officers’ involvement with Mr Candeloro leading up to the crash, an inquest was required to be held in order to investigate whether the death was caused or contributed to by any action of a member of the police force, pursuant to (s22(1)b) the Coroners Act 1996 (WA). I held an inquest on 16 December 2020.
Mr Candeloro was a beloved son and brother and it is clear his family have experienced enormous difficulty coming to terms with his sudden, tragic death. They have described in detail how they have suffered unresolved grief while waiting to hear the full details of the circumstances of his death and they have had many unanswered questions. From the start, Mr Candeloro’s family have expressed concerns about why the police officers initially chose to follow Mr Candeloro, the manner in which the police officers followed Mr Candeloro, as well as why the police officers did not see the crashed motorcycle immediately and stop and render first aid.
At the inquest, the two police officers who attempted to intercept Mr Candeloro, gave evidence, as well as a number of the people who heard the crash and came to see if they could assist. In addition, the forensic pathologist who performed the post mortem gave evidence, as well as a number of police officers who were involved in the later coronial investigation. I had hoped that hearing from these witnesses would help to answer the many unanswered questions of Mr Candeloro’s family, as well as
[2021] WACOR 13 assisting me to consider the question of causation and contribution, if any, by police.
The analogy was given at the inquest of the evidence being led to try to put the jigsaw puzzle pieces together to create a full picture of what occurred.
Unfortunately, since the inquest hearing, I have received a large amount of additional material from Mr Candeloro’s next of kin, which indicates they believe “many of the jigsaw puzzle pieces are missing”1 still. Nevertheless, based upon the evidence they have seen and heard, they remain of the belief that the police should be held responsible for Mr Candeloro’s death.
I regret that I am unable to answer some of the questions Mr Candeloro’s family still consider to be unanswered. However, I am satisfied that I have sufficient information to complete my task as coroner. I do not accept the assertions of Mr Candeloro’s family that witnesses have lied or deliberately omitted information. I formed the view that all of the witnesses who appeared at the inquest gave an honest and reliable account of events, allowing for understandable gaps in memory due to the passage of time. I am supported in my consideration of the veracity and reliability of the witnesses by the objective evidence available, such as the CCTV footage, radio call logs and AVL data from the police car, and the independent evidence of civilian witnesses.
I set out my reasons below, but it is sufficient to say at this stage that based upon the evidence before me, I am satisfied the police officers cannot be said to have caused or contributed to Mr Candeloro’s death. While his driving behaviour may have been prompted by a desire to get away from police, it was Mr Candeloro’s decision to drive in an inherently dangerous manner that tragically led to the crash that caused his death. I note he had methylamphetamine in his system at the time of the crash.
Sadly, it is well known in this jurisdiction that this drug can cause drivers to behave in a manner that puts their lives in danger when on the roads, particularly when riding a motorcycle.
Mr Candeloro was the father of two sons and also had a very close relationship with his mother and sister and extended family. Mr Candeloro’s family had suffered the loss of a number of close family members prior to his own death, including his father and another sister, which had brought the remaining family members even closer together.2 Mr Candeloro’s sudden death was a further profound loss for his family.
Mr Candeloro was described by his family as a man who was very respected in the community.3 He worked as an electrician, including on a mining project in French Polynesia, and ran his own business as a fire alarm technician. He was said to be a free spirit, always full of energy and having a huge zest for life.4 1 Email to Coroner from Linda Trinick on behalf of the Candeloro Family dated 21 December 2020.
2 Email to Counsel Assisting from Linda Trinick dated 27 October 2019.
3 Email to Counsel Assisting from Linda Trinick dated 27 October 2019.
4 Funeral Service booklet for Mr David Candeloro.
As a young man he had been a skilled junior soccer player. As an adult, he still liked to be active. Mr Candeloro particularly loved camping, fishing and going to the beach with his sons, who he had taught to fish after learning from his own father. He also enjoyed riding his Harley Davidson motorcycle, playing pool and spending time with his extended family and many friends.5 He was doing some of these favoured activities shortly before he died, having spent time with friends playing pool before he began riding his Harley Davidson home that evening. Sadly, he did not make it home.
Mr Candeloro had been playing that evening in a pool league at Miss Q’s Pool and Entertainment Centre in Reserve Drive, Mandurah, with his girlfriend, Nicola Johnson, and other friends. After they had finished at about 9.15 pm, Mr Candeloro paid for a 12 month membership at the venue and then walked with Ms Johnson to the carpark. She got in her car and he started up his Harley Davidson. They both left the carpark at about 9.22 pm to drive back to Mr Candeloro’s house in Madora Bay.6
Ms Johnson and Mr Candeloro were both travelling together for the first part of their journey, before he moved off the road into a shopping centre. Ms Johnson drove slowly as she was hoping Mr Candeloro would catch back up with her. As she was driving through the roundabout at the intersection of Guillardon Terrace and Currancy Lass Rise, she accidentally put her car lights on high beam and noticed a police paddy wagon approaching, which then turned right. She drove on and turned eventually onto Challenger Road, where she observed another police vehicle. That police vehicle turned left from Challenger Road onto Lord Hobart Drive and headed towards Mandurah Road.
Ms Johnson noted in her statement that after she saw the second police vehicle, she thought “should I give Dave a call to let him know”7 but then decided not to call him.
She continued on and reached Mr Candeloro’s house in Albion Road, Madora Bay, at 9.33 pm.
6 Exhibit 1, Tab 7B.
7 Exhibit 1, Tab 7B [54].
8 Exhibit 1, Tab 7B.
Senior Constable Keith Abbott and Senior Constable Martin Kirkbride were both stationed at the Traffic Enforcement Group 1 at Mandurah Police Station in July 2019.
Senior Constable Abbott had been a traffic officer for around 40 years and his dayto-day role at the time in WA Police was traffic enforcement.9 It is fair to say he was a very experienced traffic officer.
Senior Constable Kirkbride was less experienced in the WA Police, having only joined the force in 2014, but he had also served as a police officer in Northern Ireland for a number of years before coming to Western Australia.10
On Wednesday, 3 July 2019, the two officers were rostered on duty from 2.00 pm until midnight and were sent out on the road to conduct traffic patrols. They were allocated a marked Holden Commodore sedan with the call sign TS221.11
At about 9.30 pm, Senior Constable Abbott was driving the police car north along Mandurah Road in Meadow Springs and Senior Constable Kirkbride was in the front passenger seat. As they approached the intersection of Meadow Springs Drive, both police officers saw a motor cycle turn right out of Meadow Springs Drive onto Mandurah Road and proceed north. Senior Constable Kirkbride recognised it as a black Harley Davidson motorcycle. They both noted that the motorcycle appeared to accelerate quickly as it headed away north and by the time their traffic lights had gone green, the motorcycle had passed the entrance to Ronsard Drive. Senior Constable Kirkbride recalled that Senior Constable Abbott said, “We’ll have a look at that I think”12 and the police began to follow the motorcycle.
Senior Constable Abbott explained at the inquest that the motorcycle’s heavy acceleration had caught his attention and although at that time it looked like it was only going to accelerate up to the speed limit of 80 km per hour, he thought he would follow the motorcycle to check his speed and possibly stop and talk to the rider if he continued to ride at speed.13
The police officers did not know the identity of the motorcycle rider at the time, but it is not in dispute that it was being ridden by Mr Candeloro. He was the owner of the Harley Davidson motorcycle, which was appropriately registered. He had apparently bought it as a present for himself a couple of years before around Father’s Day 2017.14 Mr Candeloro had a valid driver’s licence to ride a motorcycle, although the licence was not the right class for the engine size of the motorcycle.15
11 Exhibit 1, Tab 12 and Tab 13.
12 Exhibit 1, Tab 13 [9].
14 Exhibit 1, Tab 7B.
15 Exhibit 1, Tab 6.
Senior Constable Abbott had decided that he would catch up to the motorcycle to try to check its speed, but before he could do so Mr Candeloro indicated left and then turned left onto Karinga Road in Madora Bay. Senior Constable Abbott followed Mr Candeloro’s motorcycle as it turned left but was not close enough to obtain the registration number from the licence plate.16
As they drove along Karinga Road, which has a maximum speed limit of 50 km/hr, Senior Constable Abbott estimated the motorcycle was travelling at a speed of 70 – 80 km/hr. The police radar could not pick up the speed as the vehicle was travelling in the same direction, but Senior Constable Abbott gave evidence he has been estimating speeds for his whole police career so he was relatively confident about his estimate.17
The motorcycle continued up Karinga Road and then moved onto Guillardon Terrace, still heading north, as Karinga Road veered away to the left. As he approached the roundabout at the intersection with Currency Lass Rise, Mr Candeloro braked a little and then rode through the roundabout at speed, indicating left as he exited onto Guillardon Terrace. He then accelerated away from the roundabout and moved quickly towards the next roundabout at the junction with Britawast Road. Senior Constable Kirkbride saw the motorcycle’s brakes again as Mr Candeloro drove through the next intersection, then he indicated to exit again onto Guillardon Terrace.18
Senior Constable Abbott indicated he was still trying to catch up to the motorcycle to check his speed and did not have the police car’s lights and siren activated at this stage. By this stage, the police estimated the police car was approximately 50 to 100 metres behind the motorcycle. The motorcycle could more easily navigate through the roundabouts, so this increased the gap each time.19
As the police car followed the motorcycle through the roundabout and exited, Senior Constable Abbott activated the police car’s emergency lights and siren in an effort to get Mr Candeloro to stop so they could check his licence and speak to him about the manner of his driving.20 Senior Constable Abbott and Senior Constable Kirkbride were both of the view that until that time Mr Candeloro was probably unaware the police were behind him.21
Senior Constable Abbott gave evidence he made a brief risk assessment before he turned on the emergency devices, noting it had become obvious they were not going to catch up to Mr Candeloro to check his speed (even though the police car was travelling at around 100 km/h at that stage)22 and there was very little traffic on the 16 T 14 – 15; Exhibit 1, Tab 13 and Tab 14.
18 Exhibit 1, Tab 13 and Tab 14.
21 T 16; Exhibit 1, Tab 7A, p. 30.
[2021] WACOR 13 road to pose a danger, no pedestrians around and the street lights were on, making them visible to others.23
Senior Constable Abbott believed that Mr Candeloro immediately accelerated and assumed he did so upon seeing the blue lights. They were only a short distance from the T-junction with Lord Hobart Drive and Mr Candeloro was seen to brake heavily as he turned left onto Lord Hobart Drive. It appeared the motorcycle lost traction to its back wheel and slid slightly as it made the turn. Senior Constable Abbott said he thought Mr Candeloro “nearly lost control of it” on the turn and noted the motorcycle went onto the incorrect side of Lord Hobart Drive before it travelled west.24
Senior Constable Kirkbride commented to Senior Constable Abbott that it was too dangerous to continue and he should downgrade. He recalled at the inquest that he uttered the words, “This isn’t going to end well, leave it,” followed by the words, “Downgrade and disregard.” Senior Constable Abbott agreed with him and downgraded.25 Senior Constable Kirkbride had told interviewers previously that he had initially thought there was a possibility the motorcycle rider would pull over, but once it became clear he was not intending to stop he felt they should disengage as there was no way he was going to engage a motorcycle. Senior Constable Kirkbride explained he had been to a number of fatal motorcycle accidents and from that knowledge he would not even consider asking POC for permission to conduct an evade incident involving a motorcycle, even if it was a possibility.26 Senior Constable Abbott appeared to be in agreement with him and acted accordingly by immediately disengaging.27
Senior Constable Abbott extinguished the lights and siren as he turned left onto Lord Hobart Drive and immediately decreased his speed to signal his intention of letting the motorcycle go. Senior Constable Abbott said he returned the police car to below the posted speed limit to make it very clear he was not pursuing the motorcycle. He gave evidence he made this decision because it was too dangerous to pursue the motorcycle because Mr Candeloro was riding too dangerously.28
As the police car rounded the corner, Senior Constable Abbott observed the motorcycle at the end of Lord Hobart Drive about to make a left turn onto the next street. Mr Candeloro had already reached the T-junction ahead by that stage and the police officers last observed him heading west on Lord Hobart Drive before braking and making a left turn onto Abeona Parade to travel south. I note this was in the opposite direction to Mr Candeloro’s home, which was situated north of Lord Hobart Drive in Madora Bay. This suggests that Mr Candeloro was aware of the police behind him and was perhaps making an attempt to lose them, before heading home.
25 T 19, 30; Exhibit 1, Tab 12 and Tab 13.
26 Exhibit 1, Tab 7A, p. 31.
27 Exhibit 1, Tab 7A, p. 29, 32.
Senior Constable Abbott estimated the entire intercept attempt, from the time he turned the lights on until they self-aborted, lasted no more than five to ten seconds.29 Senior Constable Kirkbride made a call over the police radio to the Police Operations Centre (POC) informing them that a motorcycle had failed to stop for them and they were now heading towards Silver Sands. He advised they had downgraded and were not pursuing the motorcycle, although they did drive west on Lord Hobart Drive and turn south on Abeona Parade, in the same direction Mr Candeloro had travelled.
Senior Constable Abbott gave evidence his plan was to resume normal patrol duties at that stage and there had been traffic complaints in that area, so he intended to drive around and look for any such behaviour. He also indicated that he intended to check the beachfront to see if the motorcycle rider had parked anywhere, as if he had he would pull over and have a chat with him.30
There was no sign of Mr Candeloro’s motorcycle when they turned onto Abeona Parade, and they continued to drive south along the beachfront as the road changed into Orestes Street. Although he accepts the motorcycle must have already crashed by that time, Senior Constable Abbott gave evidence he did not see it as the motorcycle and Mr Candeloro were hidden in very thick bush alongside the boundary fence.31
As the police officers reached the intersection with Eros Place, they drove past a red Holden Commodore sedan heading in the opposite direction on Orrestes Street. The Automatic Number Plate Recognition System in the police car alerted Senior Constable Abbott that the Commodore had a police alert related to it. Further enquiries established the registered owner of the Commodore had a suspended driver’s licence. Senior Constable Abbott turned the police car around and activated the emergency lights so they could follow the red Commodore and pull over the driver. The driver of the Commodore also executed a u-turn, near the intersection with Jannali Way, and began driving south. Senior Constable Abbott followed and the driver of the Commodore then pulled over and the police car pulled up behind it.32
Senior Constable Abbott said at that time he saw a red taillight in the bush directly opposite the police car, on the other side of the road. He turned to Senior Constable Kirkbride and said, “I hope this is not what I think it is.”33 He then got out of the police car and went over to the other side and saw there was a crashed motorcycle hidden in the bushes and a person lying there, which was Mr Candeloro.34
Senior Constable Kirkbride had observed a group of people on the footpath looking into the bushland before they had completed the second u-turn and when the red Commodore pulled over, it stopped opposite that group of people. He did not see the
[2021] WACOR 13 tail light but could see people in the bushland moving around. He left the police car and joined Senior Constable Abbott on the other side of the road to investigate.35
Senior Constable Kirkbride saw Mr Candeloro tangled up in a wire fence and it was clear he was injured. A few people were standing near him but it was unclear if they were doing anything to administer first aid. Senior Constable Kirkbride approached Mr Candeloro and asked him his name, which Mr Candeloro gave. Senior Constable Kirkbride then spoke to Mr Candeloro further to ask him where he was experiencing pain, but Mr Candeloro did not respond.
Mr Candeloro’s legs were tangled up in the wire of the fence, which meant his legs were raised slightly above his head. Senior Constable Kirkbride used his police radio to make a call to request an ambulance attend and then turned his attention to Mr Candeloro again. Senior Constable Kirkbride attempted to do some sort of assessment of Mr Candeloro to check for injuries but couldn’t identify anything remarkable. He did notice an area of blood to the right-hand side of Mr Candeloro’s torso, which made him wonder if Mr Candeloro was impaled on a sharp stick or something similar. He looked more closely to see if he could see anything on which Mr Candeloro could be impaled but didn’t want to move him too much as he was concerned Mr Candeloro may have suffered a head injury, fractured neck or spine.36
Senior Constable Abbott believed he saw a laceration on Mr Candeloro’s arm at this early stage, but was also aware that Mr Candeloro’s breathing was laboured and Senior Constable Kirkbride was focussed on the important task of ensuring Mr Candeloro continued breathing, so that appeared to be the priority.37
Senior Constable Kirkbride said if he had found the source of the bleeding he would have tried to stop it, but agreed his main focus was on ensuring Mr Candeloro continued to breathe.38 It doesn’t appear they discussed the issue at that stage.
When Mr Candeloro began to lose consciousness and his breathing was laboured, gasping for air. Senior Constable Kirkbride loosened the chinstrap on Mr Candeloro’s helmet to try and relieve some of the pressure on his neck. Senior Constable Abbott had returned to the police car to try to find cutting implements to try to remove some of the wire but was unsuccessful.39 Senior Constable Kirkbride asked if any of the bystanders could help get Mr Candeloro’s legs free so they could improve his position, and somebody came forward with wire cutters and managed to cut the wire so Mr Candeloro could be freed from the wire fence.40
Mr Candeloro’s breathing remained laboured and Senior Constable Kirkbride decided that although he was concerned about possible neck and spinal injuries, the priority was to make sure that Mr Candeloro remained breathing, so he asked a few members of the public if they could assist with putting Mr Candeloro into the
36 T 33; Exhibit 1, Tab 7A, p. 24, 34.
37 Exhibit 1, Tab 7A, p. 20.
38 Exhibit 1, Tab 7A, p. 34.
[2021] WACOR 13 recovery position, while trying to hold his neck as still as possible. After they placed him in the recovery position Mr Candeloro initially seemed to be breathing more comfortably and Senior Constable Kirkbride monitored his breathing.41
Senior Constable Abbott returned to the police car to get CPR equipment, in case it was required. When he returned he was made aware that one of the bystanders had called emergency services and an operator from St John Ambulance (SJA) was providing instructions through a phone speaker. Senior Constable Kirkbride was following the instructions of the operator to monitor Mr Candeloro’s pulse and breathing until paramedics arrived.42
Senior Constable Abbott returned to the police car to advise the Police Operations Centre of the situation then assisted to direct the two ambulances that arrived to the correct location.43
On the SJA Patient Care Record it was noted that Senior Constable Kirkwood was deep in the bushes with Mr Candeloro when the paramedics arrived. Mr Candeloro exhibited agonal breathing. Senior Constable Kirkbride informed one of the paramedics of his concern that Mr Candeloro was bleeding. He helped the paramedic cut off Mr Candeloro’s clothing, and it became apparent Mr Candeloro had a large laceration on his upper arm. Mr Candeloro had previously been wearing a leather jacket and Senior Constable Kirkbride did not think it had not shown any tears or anything to suggest the concealed injury, although it was difficult to see in the area due to the lack of lighting.44
Senior Constable Kirkbride got a tourniquet out of the paramedics’ trauma kit and gave it to the paramedic, who applied it to Mr Candeloro’s arm, then they commenced CPR on Mr Candeloro. The police officers assisted the paramedics to load Mr Candeloro into the ambulance, where CPR continued on the way to hospital.45
The Peel Health Campus triage notes indicate Mr Candeloro arrived at the hospital with CPR still in progress and he had a large traumatic injury to his left arm. After further resuscitation attempts a decision was made to cease resuscitation as there was no further evidence of cardiac activity. A doctor certified Mr Candeloro’s time of death as 10.10pm.46
44 T 34; Exhibit 1, Tab 17.
45 T 23, 34; Exhibit 1, Tab 17.
46 Exhibit 1, Tab 18.
[2021] WACOR 13 region, extending down to the bone. There were also lesser injuries (abrasions) elsewhere to the arms and the left leg. There was no obvious skeletal injury seen on the CT scan. There was evidence of resuscitation attempts, including the presence of catheters.47
Toxicology analysis of blood samples taken from Mr Candeloro showed the presence of amphetamines.48 The level of methylamphetamine was quantified and found to be 0.53 mg/L. There was also a small amount of amphetamine detected.49
At the conclusion of the examination and other investigations, Dr Cooke formed the opinion Mr Candeloro died from a severe injury to the left arm.50
Dr Cooke gave evidence at the inquest to expand upon his findings. Dr Cooke confirmed in his evidence that he thought the cause of death was an injury to the left arm. Dr Cooke explained it was an unusual fatal injury in the context of a motorcycle crash, as usually you would be most concerned about a head injury, broken neck or a chest injury.51 In this case, it was a very deep injury across the centre of the arm, more or less across the elbow crease region. It was almost a ‘cutting type’ of injury and went through the skin, the fat and the muscle of the arm, and most likely although through the main brachial artery. Dr Cooke agreed that the injury was consistent with the history of Mr Candeloro colliding with a wire fence.52
Dr Cooke explained that with an injury like this, it would have required a fairly rapid first aid response to prevent death, “because the brachial artery is quite a large artery, it would bleed very quickly and … it’s accompanied by a large vein as well, so you’ve got two large blood vessels which are bleeding.”53 Dr Cooke indicated that it would “require a tourniquet to be properly applied to the upper part of the arm to stop the bleeding. It would have to be a very quick application of a very tight tourniquet to prevent significant blood loss,”54 within the order of two or three minutes.
I note that Senior Constable Kirkbride estimated that they had lost sight of the motorcycle approximately 5 minutes before he approached the crash scene,55 although the radio communications would suggest it was more in the order of 3 minutes. Based on the radio communications, at least a couple of minutes had likely elapsed from the time Mr Candeloro crashed and sustained his injury and the arrival of the police officers at the scene, so the opportunity to implement life-saving action had likely passed by the time the police arrived and made an assessment of Mr Candeloro.
47 Exhibit 1, Tab 4A - 4B.
48 Exhibit 1, Tab 4A.
49 Exhibit 1, Tab 5B.
50 Exhibit 1, Tab 4B.
55 Exhibit 1, Tab 7A, p. 23.
Dr Cooke also indicated that the presence of amphetamines in Mr Candeloro’s blood, which will affect the heart, can make a fatal outcome more likely, because it is putting the heart under greater strain.56
Other than the effect on the heart, Dr Cooke does not have the expertise to talk about the specific effects of the levels of amphetamines found in Mr Candeloro’s blood, but he was able to give evidence in general terms about how the drug affects people.
Dr Cook explained that amphetamines make a person feel alert and euphoric but can also make a person feel confused. Significantly in this case, it can also increase a person’s tendency to engage in risk-taking behaviour and, in that sense, “it can be a very dangerous drug to take.”57
POLICE INVESTIGATION Major Crash Investigation
This section has responsibility for investigating fatal crashes in terms of any criminal culpability and for the coroner. The report outlined the conduct of various officers and other people involved in the crash investigation.
Senior Constable Feldmann from the reconstruction section of MCIS inspected Mr Candeloro’s motorcycle and noted there was damage consistent with a highspeed collision with the wooden poles and wire fence that were present where Mr Candeloro came to rest.59 Senior Constable Feldmann also inspected the police car TS221 and found no damage to suggest it had been in contact with the motorcycle.60 An examination of the motorcycle by qualified automotive mechanics found no defects that were likely to have contributed to the occurrence of the crash.61
A location sketch and photographs from a preliminary crash investigation conducted by a Senior Road Safety Investigator from Main Roads WA, which was provided to MCIS, shows the path of Mr Candeloro’s motorcycle and how it failed to make the turn.
59 Exhibit 1, Tab 6, p. 4.
60 Exhibit 1, Tab 6, p. 4.
61 Exhibit 1, Tab 6, p. 4 and Tab 16 and Tab 21.
CCTV footage that was obtained from a residence on the corner of Jannali Way and Orestes Street was also considered as part of the investigation, and it supported the conclusion the reason Mr Candeloro’s motorcycle failed to make the turn was due to high speed.62 The CCTV footage shows the motorcycle approaching the corner of Jannali Way and Orestes Street and also captures the sound of the motorcycle’s engine as the motorcycle is accelerating on approach. The sound was also heard by people living in the nearby houses. The brake light of the motorcycle is seen to activate just before the motorcycle leaves the roadway and crashes into the fence and bushes, and there were tyre lock up marks noted at the scene consistent with heavy braking. However, the braking was insufficient to save him at that point.63
Time over distance analysis was conducted from the CCTV footage by Senior Constable Feldmann, which indicates the average speed of Mr Candeloro’s motorcycle as it approached was between 97 and 102 km/h and then in those last seconds, when braking, it was between 85 km and 90 km/h.64 Orestes Street is a residential road, classed as a built-up area, and has a speed limit of 50 km/h,65 so Mr Candeloro was travelling at approximately twice the allowed speed limit as he approached the bend.
The police car was noted on the CCTV footage to not come into vision until about 30 seconds after the motorcycle has crashed. It was noted the degree of separation between the motorcycle and TS221 increased over time, indicating the motorcycle continued to accelerate beyond that of the police over an extended period of time and distance.66
It was ascertained during the investigation that Mr Candeloro held a motorcycle licence but was not licenced to ride the Harley Davidson motorcycle he was riding that evening. His licence only permitted him to ride a motorcycle with an engine up to 650cc, whereas this motorcycle was more powerful than that, at nearly 1300cc (1246cc to be exact).67 I note the general evidence was that Mr Candeloro appeared to be a competent rider,68 so it would seem he was still comfortable riding a more powerful motorcycle than his licence permitted, but it would have been a reason why he would not have wanted to be pulled over by police as there could be consequences for not having the right class of licence. It should be noted the consequence would only be a fine in those circumstances, but there is also the fact Mr Candeloro was speeding, had failed to stop for police and had methylamphetamine in his system, all of which could result in charges or infringements.69 Mr Candeloro had previously been issued with 20 traffic infringement notices, all but two of them for speeding.70 62 Exhibit 1, Tab 6 and Tab 7A.
63 T 80 – 81; Exhibit 1, Tab 20.
64 T 71 – 72; Exhibit 1, Tab 6 and Tab 7A and Tab 20.
65 T 71; Exhibit 1, Tab 6, p. 3.
66 T 82; Exhibit 1, Tab 6, p. 5.
6767 Exhibit 1, Tab 6, p. 10.
70 Exhibit 1, Tab 6, p. 10.
As part of the Major Crash Investigation, various civilian witnesses who were in the area at the relevant time were also spoken to and statements were taken.71 Some of those witnesses also attended the inquest to speak to their statements.
One of those witnesses, Mr Moses Eggmolesse, was sitting in a parked car with his girlfriend at the relevant time, in the car park near Karinga Road and Orestes Street in San Remo. They were eating a late dinner in the car when they heard the sound of a motorcycle approaching. It sounded loud even though their windows were up.
Mr Eggmolesse recognised the sound of the engine as a Harley Davidson and as he looked out the window he “saw it fly through”72 the corner. Mr Eggmolesse described the sighting of the passing motorcycle as “very quick, very brief”73 and he attributed this to the motorcycle travelling at speed, which he estimated to be at approximately 70 to 80 km/h as it moved through the dog leg of the corner.74 In his opinion the motorcycle was travelling “was too fast for the area and the road it was on.”75
Mr Eggmolesse estimated he only saw the motorcycle for a couple of seconds as it went past and he didn’t see it turn as it moved past the traffic island, so he thought it probably moved onto the incorrect side of the road, although he didn’t see exactly how it passed through the corner. Importantly, Mr Eggmolesse did not see a police car behind the motorcycle, nor see police lights in the distance or hear a police car siren at that time. It would appear that Mr Eggmolesse did not see the police car travelling behind Mr Candeloro, but did notice it a few minutes later when the police were trying to pull over the driver of the red Commodore. He saw the red Commodore execute a u-turn then saw the police car for the first time as it followed behind the red Commodore with its lights on.76
Another civilian witness, Mr Hayden Michaels, was in a different location to Mr Eggmolesse that evening. Mr Michaels lived in a house looking out onto the area where Mr Candeloro’s motorcycle crashed. He was studying at home when he heard the sound of the motorcycle approaching and he formed the impression the motorcycle was speeding, based upon the sound he could hear. He could not hear any police sirens at that time, only the sound of the motorcycle engine. Mr Michaels then heard a scratching noise, like metal on bitumen, which prompted him to stand up and look out the window. He looked out into the bushes and could just make out a red brake light. Mr Michaels deduced from the sound he had heard and the brake light that a motorcycle had crashed. He told his mother and then rushed out the door to see if he could help.77
By the time Mr Michaels had gone downstairs and walked out his front door and up to the crash scene (about 100 metres from his home), other bystanders were already present trying to assist. A police car and the red Commodore were also already
74 T 58; Exhibit 1, Tab 8.
75 Exhibit 1, Tab 8, [16].
76 T 59 – 61; Exhibit 1, Tab 8.
77 T 62- 63; Exhibit 1, Tab 11.
[2021] WACOR 13 parked nearby. Mr Michaels estimated it had taken him a couple of minutes from the time he first heard the crash to reaching the scene.78
Mr Michaels did not cut the wire that was entangling Mr Candeloro’s legs, although he acknowledged this may have been done by someone else with his bolt cutters.79
Another resident in a house near the crash site heard the sound of the motorcycle approaching, which he did not think sounded like it was going very fast, but he then heard a thud noise and when he looked out the window he could see a red tail light in the bushes in the sand dunes and heard a moan. He went to help and found Mr Candeloro tangled in the wire fence in the bush. He told his son to call an ambulance and not long after the red Commodore and police car arrived.80
The driver of the red Commodore, Ashley Allan, provided a statement to police that he was heading home with a friend after doing laundry. He was driving his friend’s car as his friend did not have a driver’s licence. As they were heading along the beach they passed a police car that was driving normally and did not have any flashing lights on. At the same time they passed the police car, Mr Allan looked to the left and saw a red tail light in the bush and noted the wire fence was messed up.
He realised something had gone into the dunes, so he did a u-turn to head back to that location and investigate further. The police car passed him again and as Mr Allan pulled up opposite where he had seen the tail light, he noticed the police car pull up behind him with lights flashing. Mr Allan crossed the road and a police officer followed him and they found Mr Candeloro in the bush. Mr Allan had some first aid training so he tried to help the police to assist him, but noted Mr Candeloro did not look good at that time.81
Internal Affairs Unit Investigation
80 Exhibit 1, Tab 9.
81 Exhibit 1, Tab 10.
[2021] WACOR 13 involving police. Detective Sergeant Moore considered whether the actions of the police officers conformed with the relevant WA Police policies and procedures.
Detective Sergeant Moore interviewed Senior Constable Abbott and Senior Constable Kirkbride and also considered the evidence of civilian witnesses and the CCTV footage.83 At its highest, an investigation of this kind can lead to criminal charges and can also lead to internal disciplinary charges, if it is found that the conduct of the police officers was wanting.
Detective Sergeant Moore considered the two police officers’ conduct in this case particularly in relation to the WA Police Emergency Driving Policy, in terms of the intercept driving component, as they were engaged in an attempt to intercept Mr Candeloro before he drove away at speed and they abandoned their attempt to intercept him.84
At the conclusion of the IAU investigation it was found that there was no evidence to indicate that Senior Constable Abbott or Senior Constable Kirkbride failed to comply with the policy and procedure in regard to conducting intercept driving.85 The AVL data, which is information communicated by a device in the police car that shows the position of the vehicle and its approximate speed at various points, generally corroborated the accounts of the two police officers as to their manner of driving, the route they took and the general speeds they travelled at before, during and after they attempted to intercept Mr Candeloro.86 The vehicle data showed the police car reduced speed so that it was travelling below the 50 km/h speed limit as it proceeded down Orestes Street, and that also matched the CCTV footage and the officers’ radio communications with the Police Operations Centre.87 There was evidence the police car had reduced its speed to approximately 42 – 43 km/h at the time it passed the crash location.88
Detective Sergeant Moore also considered the evidence in relation to the provision of first aid to Mr Candeloro by the police officers and found it was appropriate.89
It is standard in cases such as this for involved police officers to undertake mandatory drug and alcohol testing. In this case, Senior Constable Abbott, who had been driving the police car at the relevant time, was found to have codeine in his system. Senior Constable Abbott advised he had a blinding headache when he started his shift at 2.00 pm, so he took two of his prescribed pain medication tablets that contained paracetamol and codeine. He gave evidence the medication did not cause him any dizziness or other ill-effects and simply helped relieve the discomfort of his headache.90
Detective Sergeant Moore spoke to officers in the Alcohol and Drug Testing Unit in respect of Senior Constable Abbott’s results and was advised that the codeine levels 83 T 39 – 41; Exhibit 1, Tab 7A.
87 T 51 – 52; Exhibit 1, Tab 7A.
[2021] WACOR 13 were within normal readings and there was nothing out of the ordinary in respect to the reading.91 There was no evidence to indicate the presence of the codeine affected his decision-making ability or ability to drive the police vehicle.92
Mr Candeloro’s family had brought to police attention a concerning white mark on Mr Candeloro’s motorcycle. The police investigation sought to determine how the mark was made to the back of the motorcycle. After reviewing photographs taken of the motorcycle at the scene, it was relatively apparent that the mark was not present immediately after the crash and only became apparent after the motorcycle had been recovered from the bushes. It was noted that the motorcycle was towed out by a tow truck via a metal chain attached to the rear wheel, which involved the motorcycle being dragged, and it was concluded that the mark was made during that process.93
Photographs taken of the police car on the night also showed it had no damage that might have supported a claim there was contact between the police car and Mr Candeloro’s motorcycle.94
Therefore, it was accepted by investigators that unless someone was looking towards that location, it could easily have been missed. As the two police officers did not hear the crash, they did not have a reason to look into the bushland in that area.95
Both police officers made it clear that if they had seen the crashed motorcycle, they would have stopped immediately to assist, as they did later. The IAU investigation found no evidence to indicate either Senior Constable Abbott or Senior Constable Kirkbride deliberately failed to stop at the scene of the crash on either occasion they passed it.96 I accept that the police officers did stop immediately and go to help once they realised what had occurred.
Another issue raised was why the licence registration was not located quickly. It appears the licence plate was dislodged during the crash, which was consistent with the fact Mr Candeloro’s motorcycle sustained significant damage.97 His wallet was found on him and this assisted in his identification. The relevant information was provided to an ambulance officer and it was recorded in the SJA Patient Care Record and enabled Mr Candeloro’s next of kin to be notified by hospital staff.98
96 Exhibit 1, Tab 7A, p. 66.
98 Exhibit 1, Tab 15 [18] – [19] and Tab 17 and Tab 18.
It was clear that Mr Candeloro’s family had many other questions during the investigation. Detective Sergeant Moore explained at the inquest that members of IAU attempted to liaise with Mr Candeloro’s family and identify their concerns and provide information to assist in their understanding of what occurred. As part of that process, Detective Sergeant Moore and Sergeant Alan Becker from IAU met with the Candeloro family in the early stages of the investigation to explain the process and allow them to view a copy of the CCTV footage in the hope that would provide them with some answers. However, there were other aspects of the investigation that were not provided to the Candeloro family at an early stage as the information formed part of the ongoing coronial investigation and some of that information is not generally made available publicly, such as the WA Police Emergency Driving Policy.99
From reading the materials provided by Mr Candeloro’s family, I understand one of their main concerns is that on the night of his death, they believe they were told that the police officers aborted the attempt to pull Mr Candeloro over and did not continue to follow him, but rather turned around and drove the other way. That is certainly behaviour I have known police officers to engage in during similar incidents with a motorcycle rider that has made it clear they will not stop for police.
Indeed, Inspector Hayes gave evidence that the Police Academy now teaches that the preference is to stop, turn around and go in the other direction, which takes away all the risk that a driver might look in the background and see the police back in the distance. However, although that approach would be the ideal approach, Inspector Hayes expressed the opinion that there was nothing inherently wrong with the police continuing in the same direction at 40 km/h, given the reasons provided by the officers and the fact the evidence made it clear they were not in close proximity to the motorcycle from that time.100
The evidence suggests Mr Candeloro had travelled out of the sight of police very quickly and they had turned off their lights and siren, so there is nothing to suggest Mr Candeloro believed he was still being actively pursued by police at speed. He did, however, travel in a different direction to the path he would ordinarily take to go home, suggesting he was hoping to ensure he was not followed home if the police were still following him at a distance.101
Overall, while I note that in these circumstances the ideal approach of a police officer would be to turn the police car around so that it is abundantly clear to the person on the motorcycle that they are not being actively followed by police, I accept that the police officers did enough to indicate to Mr Candeloro that they were not going to continue to try to pull him over, but turning off their lights and siren and dramatically slowing down. Unfortunately, Mr Candeloro continued to ride at excessive speed and very quickly lost control and crashed, possibly before he had a clear appreciation that he had managed to ‘get away’, as was clearly his intention.
Inspector Michael Hayes, a very senior police officer attached to State Traffic Operations and currently the inspector responsible for traffic enforcement, had reviewed all of the relevant reports and gave evidence at the inquest in relation to the police driving and the relevant policies. He noted the police were driving the appropriate class of vehicle in this case and Senior Constables Abbott and Kirkbride had the appropriate driving qualifications. They did not exceed any speed limits under the policy and did not breach any requirement in their attempt to intercept Mr Candeloro. There was no evidence to suggest they failed in their risk assessment at the time they attempted to engage Mr Candeloro, and Inspector Hayes also gave evidence he believed they made the right call in downgrading after Mr Candeloro indicating he was not going to stop and drove around the corner in a dangerous manner. Inspector Hayes commented that all of the police conduct that he reviewed was in compliance with the relevant policy and guidelines, including taking account of the fact that motorcycles are inherently dangerous so the vulnerability of the rider is an important factor to take into account.102
Inspector Hayes commented that the WA Police Emergency Driving Policy in relation to intercept driving is “probably the most live document in WA Police and continues to be reviewed.”103 It focuses on police officers aiming to enforce the road laws but if a driver fails to stop the focus moves to resolution strategies and proper risk assessments completed by well-trained drivers. Inspector Hayes indicated that the focus is continuing to move towards engaging less in pursuits as technology provides alternative options, with the primary aim always being to keep the motoring public, the general public and the police officers themselves safe.104
I am satisfied that the WA Police Emergency Driving Policy appropriately focusses upon risk assessments that prioritise the safety of members of the public and police officers and that the two police officers properly applied that policy in this case. I am satisfied that the behaviour of the two police officers, Senior Constable Abbott and Senior Constable Kirkbride, did not cause or contribute to the death of Mr Candeloro in the relevant sense. Their attempt to pull Mr Candeloro over was initiated in furtherance of a legitimate law enforcement action and an ongoing risk assessment was undertaken as required by the Emergency Driving Policy and Guidelines. There was no elevated risk to Mr Candeloro until he failed to stop and accelerated away at speed from the police. Once it was apparent that he was not going to stop and was prepared to drive dangerously to get away from them, the police officers immediately decided not to engage Mr Candeloro, in order to reduce the risk to him and other road users.
Senior Constable Abbott expressed sadness and regret over Mr Candeloro’s death, but indicated that having thought a lot about what had occurred and could not see anything he might have done differently other than not try to engage Mr Candeloro at all. However, there was nothing at the time to suggest that Mr Candeloro would react in such an extreme manner when the police attempted to pull him over.105 102 T 87 – 88; Exhibit 1, Tab 23.
103 T 91, Exhibit 1, Tab 23.
104 T 90 – 91; Exhibit 1, Tab 23
Senior Constable Kirkbride extended his condolences to Mr Candeloro’s family in his evidence and expressed his wish that it had been within his ability to help him further on the night. It is clear that Senior Constable Kirkbride had found performing his role as the first aid responder to Mr Candeloro extremely challenging, and with the benefit of hindsight he said he wished he had removed Mr Candeloro’s clothing earlier, although that was not part of the usual first aid training.106
It would also appear that there was a possible missed opportunity for the two police officers to have discussed what they saw in terms of their assessment of Mr Candeloro and his injuries, as it would appear Senior Constable Abbott might have recognised the injury to Mr Candeloro’s arm earlier than Senior Constable Kirkbride. However, given the evidence of Dr Cooke, it would appear that by the time that injury was identified even by Senior Constable Abbott, the relevant time period to save Mr Candeloro through the prompt application of a tourniquet had probably passed.
Detective Sergeant Moore and Senior Constable Clarke also extended their condolences to Mr Candeloro’s family and apologised if they found the police investigation process less informative than they had wished, but they explained that there focus was to prepare a full coronial brief so that the family would get the required information during the inquest hearing.107
I note that after the inquest hearing had concluded, Mr Candeloro’s family wrote to the Court to raise more questions they believed had not been answered during the inquest and to make submissions about what they believe occurred on the night.108 I have considered the questions they raise and their comments on the evidence and their submissions about what conclusions I might reach. To the extent that it is possible to isolate the issues raised, I address them below.
Firstly, Mr Candeloro’s family appear to suggest that the police officers changed their statements to support a version of events which they say was more favourable to police than the original accounts given. I note in the IAU investigation the investigators went to some lengths to establish whether the two police officers did provide differing accounts at any stage and no evidence is contained in the brief of evidence to support this assertion. It would appear that the family’s belief of a change in account may arise from what they were told initially by Major Crash investigators very shortly after the incident that the police did not follow Mr Candeloro. Whatever may have been said by the investigators, I am satisfied that the two police officers involved have provided a consistent account of events throughout, and their evidence is supported by objective evidence and the evidence of independent witnesses. Therefore, there is no evidence that the relevant police officers changed their stories. Rather, it is possible that the initial comments were made to the family before a full understanding of events was gained by the investigators. Whilst that is regrettable, it does not change the evidence upon which I am bound to make findings.
108 Submissions provided by email on behalf of the Candeloro Family on 5 January 2021.
Mr Candeloro’s family also raised some concerns about inconsistencies in the evidence as to CPR being provided to Mr Candeloro by police at the scene, which was clarified by Senior Constable Kirkbride, who took the lead in providing first aid to Mr Candeloro until paramedics arrived.109 Further, concerns were raised about inconsistencies in police accounts about whether police officers were first on the scene, given the weight of the evidence indicated that there were civilians already present when police stopped behind the Commodore and crossed the road to the crash scene.110 In particular, Mr McPhail, a nearby resident appears to have got to the scene first, and he mentions seeing Mr Candeloro and telling his son to call an ambulance, before he turned around and saw a police car had arrived.111
The suggestion appears to be that Senior Constable Abbott must have lied, in the face of this evidence, by asserting that the police were first on the scene and performed CPR. I do not accept that Senior Constable Abbott’s evidence should be viewed in that light. As to the CPR, it appears he was under the impression this was being performed by Senior Constable Kirkbride, when there were efforts to improve his breathing, and this prompted Senior Constable Abbott to go and look for equipment from the police car. As to other people being at the scene when police arrived, Senior Constable Abbott was not explicit about who was in attendance, and it is not unreasonable that his focus was on the motorcycle rider and not the civilians.
Mr Candeloro’s family raise many other issues in their later correspondence in relation to the attempted intercept and how the police officers conduct did or not comply with the relevant policy. I have addressed the evidence of their conduct and its compliance with the policy above, and indicated I am satisfied there was no breach by either police officer.
There is also an allegation that the police car deliberately rammed Mr Candeloro’s motorcycle. I address that allegation below, but I emphasise at this stage there is absolutely no evidence to support that allegation. The evidence is that the police car had no damage and the white mark on the motorcycle was caused by the retrieval of the motorcycle from the dunes.
Mr Candeloro’s tragic death was sadly a result of high speed and the inherent vulnerability of motorcycle riders. It is also likely that the methylamphetamine in his system played a role in his decision-making on the night.
As I have commented in other inquests, methylamphetamine is increasingly prevalent in our society and it is sadly not uncommon for coronial inquests to arise from the death of a methylamphetamine affected driver fleeing from police. As an example, in 2017 the State Coroner conducted an inquest into six deaths that followed police pursuits and/or intercepts where four of the five involved drivers
110 Exhibit 1, Tab 10 and Tab 13 [32] 111 Exhibit 1, Tab 9.
[2021] WACOR 13 evading police had taken methylamphetamine that had significantly impaired their physical and mental faculties.112 Similarly, in 2019 I conducted an inquest into the death of a motorcycle rider affected by methylamphetamine who avoided being pulled over by police by driving away at high speed, leading to his death when he crashed as he failed to negotiate an exit due to his high speed.
Expert evidence from Professor David Joyce, a Clinical Pharmacologist and Toxicologist, in other inquests where deceased drivers have evaded police and been found later to have had methylamphetamine in their system, has been to the effect that the literature shows methylamphetamine users are at particular risk of involvement in high-speed police pursuits, often resulting in death. Some of the effects of methylamphetamine intoxication that may contribute to the decision to undertake and continue a high-speed flight include: Firstly, perhaps a good reason to avoid apprehension (eg: aware of their intoxication which may be detected, no licence, etc); Paranoid beliefs about the pursuing vehicle and police; Impetuosity and preparedness to take dangerous risks; Energy, aggression and a propensity to violence; An indifference to personal safety that merges into suicidality; and Indifference to the safety of others.113
I accept that not all of these factors would necessarily have applied to Mr Candeloro, but it provides some context to why he may have behaved in a way that struck his family as extremely out of character for him. Further, I do make the comment that contrary to the family’s submissions, it cannot be said that speeding was completely out of character for Mr Candeloro, given his previous traffic infringements for exceeding the speed limit on multiple occasions.
Ultimately, Mr Candeloro made a choice on the night not to pull over for the police, but instead to ride away at high speed in a residential area. His decision-making may or may not have been affected by methylamphetamine, but was nevertheless his decision. Contrary to Mr Candeloro’s family’s assertion in submissions provided after the inquest, there is no evidence to support a finding that the police car ever came into contact with Mr Candeloro’s motorcycle, let alone that the police officers deliberately rammed his motorcycle, causing him to flee from police in fear for his life.114
On the evidence available, I find that death arose by way of accident.
112 Inquest into the deaths of Kuldeep Singh, Sean Duncan Barrett, Gavin Wayne Fryer, Jordan Damon Rundell, Kyra Marjorie Narrier and Hassan El Bakdadi, delivered 29 December 2017.
113 Inquest into the death of Aaron Stephen Marsh, delivered 22 November 2019, [48] - [50].
114 Submissions provided by email on behalf of the Candeloro Family on 5 January 2021.
Following the many losses they had already suffered in their close family, it is apparent that Mr Candeloro’s sudden death had a profound impact on Mr Candeloro’s remaining relatives. The family had a number of concerns about the information they had been told at an early stage in the police investigation, and wanted to be reassured there would be a proper investigation into his death to ensure that the police officers involved carried out their duties lawfully and did not play a role in Mr Candeloro’s death. I am satisfied such an investigation has been properly carried out.
I am required by statute to investigate by inquest any deaths where there is a question as to whether the conduct of police could be said to have caused or contributed to the death. This often involves a consideration of WA Police procedures and policies and whether the individual officers can be said to have complied with those procedures and policies. In this case, I have heard from the police officers involved, as well as other police officers involved in the investigation and civilian witnesses. Based upon all of the evidence, I am satisfied there is no adverse comment to be made against any of the individuals involved, or any recommendations to be made in relation to the current relevant WA Police Emergency Driving Policy.
The heartbreak of Mr Candeloro’s family at the loss of their beloved family member is undeniable and I understand that the outcome of this inquest will not satisfy their desire for someone to be held responsible for his death.
S H Linton Coroner 20 April 2021
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