Inquest into the Death of Shaun Andrew WILLIS

[2022] WACOR 3 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : PHILIP JOHN URQUHART, CORONER HEARD : 5-6 October 2021

DELIVERED : 17 JANUARY 2022 FILE NO/S : CORC 17 of 2019

DECEASED : WILLIS, SHAUN ANDREW Catchwords: Nil Legislation: Nil Counsel Appearing: Ms S Tyler assisted the Coroner Ms M Hemsley appeared on behalf of the Western Australian Police Force Case(s) referred to in decision(s): Nil

[2022] WACOR 3 Coroners Act 1996 (Section 26(1))

RECORD OF INVESTIGATION INTO DEATH I, Philip John Urquhart, Coroner, having investigated the death of Shaun Andrew WILLIS with an inquest held at Perth Coroner’s Court, Central Law Courts, Court 85, 501 Hay Street, PERTH, on 5-6 October 2021, find that the identity of the deceased person was Shaun Andrew WILLIS and that death occurred on 8 March 2019 at 279A Collins Street, Piccadilly, from ligature compression of the neck (hanging) in the following circumstances: Table of Contents

[2022] WACOR 3

[2022] WACOR 3 INTRODUCTION The deceased (Mr Willis) died on 8 March 2019 at his home address, from ligature compression of the neck (hanging).

Although Mr Willis’ death was a reportable death within the meaning of section 3 of the Coroners Act 1996 (WA) (the Act) as it was unexpected, an inquest into his death was not mandatory as it did not fall within any of the circumstances set out in section 22(1) of the Act.

However, pursuant to section 24(1) of the Act, Amanda Stevenson (Mr Willis’ partner) asked that an inquest be held into his death by letter dated 2 April 2019.

On 29 June 2020, the State Coroner determined that an inquest into Mr Willis’ death was desirable within the meaning of section 22(2) of the Act so that a coroner could examine the response of the Western Australian Police Force (WAPF) to Ms Stevenson’s request for a welfare check of Mr Willis. The State Coroner noted that it was not suggested that any police officer from the WAPF caused or contributed to Mr Willis’ death, rather the inquest was to examine the adequacy of any guidance provided to police officers in the WAPF’s existing policies relating to welfare checks.

I held an inquest into Mr Willis’ death at Perth on 5-6 October 2021. The following witnesses gave oral evidence:1 i. Constable Aaron Curtis, the police officer who interviewed Mr Willis on 7 March 2019; ii. Senior Constable Anthony Welch, one of the two police officers who attended Mr Willis’ house at about 3.00 am on 8 March 2019; 1 I have used the rank of the police officers as of 8 March 2019, except in the case of Inspector Davis and Assistant Commissioner McCabe whose cited ranks were at the time of the inquest.

[2022] WACOR 3 iii. Constable Carly Dennis-Watson, the other police officer who attended Mr Willis’ house at about 3.00 am on 8 March 2019; iv. First Class Constable Dean Preedy, the police officer who received Ms Stevenson’s request for a welfare check of Mr Willis; v. Senior Constable Lorraine Dempsey,2 one of the two police officers who conducted the first welfare check on 9 March 2019; vi. Constable Francesco Voglino, one of the two police officers who conducted the second welfare check and one of the three police officers who conducted the final welfare check on 9 March 2019; vii. First Class Constable Joel Corrie, one of the three police officers who conducted the final welfare check on 9 March 2019; viii. Inspector Craig Davis, Acting Superintendent of the GoldfieldsEsperance District Office; ix. Assistant Commissioner Joanne McCabe, Assistant Commissioner - Operations Support.

The documentary evidence at the inquest comprised of one volume that was tendered as exhibit 1 at the commencement of the inquest and a second exhibit (exhibit 2) that was tendered during the inquest.

My primary function has been to investigate the death of Mr Willis. It is a fact-finding function. Pursuant to section 25(1)(b)(c) of the Act, I must find, if possible, how Mr Willis’ death occurred and the cause of his death. Given the known circumstances in this matter, those findings can be made without difficulty.

Pursuant to section 25(2) of the Act, I may comment on any matter connected to Mr Willis’ death, including public health or safety or the administration of justice. This is an ancillary function of a coroner.

Section 25(5) of the Act prohibits me from framing a finding or comment in such a way as to appear to determine any civil liability or suggest a person is 2 Senior Constable Dempsey’s surname was Welch as of 8 March 2019, however I have used her current surname to avoid confusion with Senior Constable Anthony Welch.

[2022] WACOR 3 guilty of an offence. It is not my role to assess the evidence for civil or criminal liability and I am not bound by the rules of evidence. As identified by the State Coroner, the focus of the inquest was to examine the response by police to Ms Stevenson’s request for a welfare check and the adequacy of existing WAPF policies relating to welfare checks.

In making my findings, I have applied the standard of proof as set out in Briginshaw v Briginshaw (1938) 60 CLR 336, 361-362 (Dixon J), which requires a consideration of the nature and gravity of the conduct when deciding whether a matter has been proven on the balance of probabilities.

I am also mindful not to insert any hindsight bias into my assessment of the actions by police in carrying out their welfare checks on Mr Willis.3

MR WILLIS 4 Mr Willis was born on 8 January 1965. He was 54 years old at the time of his death. He was born in Merredin and had three brothers and two sisters (one of whom is deceased). Mr Willis was a qualified train driver and drove trains, including the Prospector, for about 30 years. He also trained other drivers throughout his career. About 18 months prior to his death, Mr Willis retired from train driving and began his own business in property maintenance. He lived in Piccadilly, a suburb of Kalgoorlie. He shared the house with another man, who was overseas at the time of Mr Willis’ death.

Mr Willis was married in November 2001 and he separated from his wife approximately 12-15 months before his death. Their two teenage children at the time, a daughter and a son, lived with their mother in the former family home in South Kalgoorlie.

3 Hindsight bias is the tendency after the events to assume the events are more predictable or foreseeable than they really were: Dillon H and Hadley M, The Australasian Coroner’s Manual (2015) 10 4 Exhibit 1, Tab 5, Report of First Class Constable Cervenak dated 29 July 2019; Exhibit 1, Tab 9, Statement of Janelle Willis dated 9 March 2019; Exhibit 1, Tab 10, Statement of Amanda Stevenson dated 25 April 2019

[2022] WACOR 3 The relationship between Mr Willis and his ex-wife was a tumultuous one, with over 20 recorded family violence incidents reported to the WAPF during their marriage and following their separation.5 Mr Willis began his relationship with Ms Stevenson, who is a police officer with the WAPF, in September 2018. Although Ms Stevenson lived in Perth, they would see each other every three weeks or so and spend extended time together. They spoke to each other every day and sent text messages to each other regularly.

Mr Willis was a fit man. He competed in triathlons and was a member of the local triathlon club in Kalgoorlie. At the time of his death, he was training for marathons, including the Goldfields Pipeline marathon in July 2019.

Mr Willis did not have any underlying health conditions and he had not been diagnosed with any mental health issues.

Mr Willis was known to put others before himself. He adored his two children, who were always welcomed into his home whenever they wanted to visit.

EVENTS LEADING UP TO MR WILLIS’ DEATH Altercation with his ex-wife 6 At about 4.30 am on 26 February 2019, Mr Willis attended the home of his ex-wife uninvited. He began banging on her bedroom window before she let him in. Once inside, Mr Willis began arguing with his ex-wife. Mr Willis’ ex-wife later alleged that, during the argument, he struck the area of her right eye with his fist.

5 Exhibit 1, Tab 19B, WAPF Intelligence Report, p.1 6 Exhibit 1, Tab 9, Statement of Janelle Willis dated 9 March 2019; Exhibit 1, Tab 19C, WAPF Incident Report 010319 08516548; Exhibit 1, Tab 11, Statement of Constable Aaron Curtis dated 22 March 2019

[2022] WACOR 3 On 1 March 2019, Mr Willis’ ex-wife attended the Kalgoorlie Police Station and made a complaint that she had been assaulted by Mr Willis on 26 February 2019 (the complaint).

The arrest of Mr Willis on 7 March 2019 7 Constable Aaron Curtis, from Kalgoorlie Police Station, was responsible for the police investigation into the complaint.

At about 4.45 pm on 7 March 2019, he attended Mr Willis’ home address in company with another police officer. There, he placed Mr Willis under arrest for aggravated common assault. Mr Willis was then taken to the Kalgoorlie Police Station, where he agreed to participate in an electronically recorded record of interview. This interview commenced at about 5.35 pm and was completed around 6.30 pm. During the course of that interview, Mr Willis admitted attending his ex-wife’s address just after 5.00 am on 26 February 2019, but denied that he punched her. He also admitted seeing his ex-wife with a black eye two days later, however he denied that he was responsible for that.

After the interview, Mr Willis was taken to the lockup at Kalgoorlie Police Station whilst Constable Curtis discussed the matter with his supervising sergeant. The decision was made that Mr Willis would be charged.

Constable Curtis then attended the lockup and advised Mr Willis he was going to be charged with one count of aggravated common assault. He was also served with a Family Violence Restraining Order (FVRO) which prevented him from attending his ex-wife’s address or communicating with her in any way.8 Mr Willis was then released from police custody at about 9.15 pm.

Although Constable Curtis offered him a lift back to his home, Mr Willis declined and stated that he would prefer to walk.

7 Exhibit 1, Tab 11, Statement of Constable Curtin dated 22 March 2019 8 Exhibit 1, Tab 17, Violence Restraining Order 2019 00079

[2022] WACOR 3 Throughout his interaction with Mr Willis on 7 March 2019, Constable Curtis observed him to be calm and compliant at all times, even after being told he was going to be charged and after being served with the FVRO. The police officer in charge of the lock up that night stated Mr Willis was “as good as gold.”9 Not surprisingly, given Mr Willis’ demeanour, police who dealt with him on 7 March 2019 had no concerns for his well-being.10 Mr Willis’ attendance at his ex-wife’s house on 8 March 2019 11 At about 1.30 am on 8 March 2019, Mr Willis drove to his ex-wife’s address.

This was in contravention of the FVRO he had been served with just several hours earlier.

Mr Willis began banging on the window of his ex-wife’s bedroom, which was at the front of the address. She told him a number of times to go away, but he did not do so. When she did not let him into the house, Mr Willis climbed over the fence and entered the house through the rear yard. When climbing over the fence he cut his hand.

Mr Willis told his ex-wife that he had taken about 20 tablets, but he did not say what those tablets were. It appeared to his ex-wife that he was “spaced out”, and the evidence suggests this was because he was intoxicated with alcohol.12 Mr Willis also threatened to kill himself.

Mr Willis’ 16-year-old daughter was woken up by her father’s voice inside the house and she made an audio recording on her mobile phone of the conversation between her parents. Mr Willis could be heard on that audio 9 ts 5.10.21 (Preedy), p.50 10 I have viewed Mr Willis’ record of the interview with police on 7 March 2019. Throughout the interview, he gave no indication he was stressed or mentally unwell. Nor did he appear affected by alcohol.

11 Exhibit 1, Tab 9, Statement of Janelle Willis dated 9 March 2019; Exhibit 1, Tab 12, Statement of Senior Constable Anthony Welch dated 14 April 2019; Exhibit 1, Tab 13, Statement of Constable Carly Dennis-Watson dated 7 April 2019 12 The results of the toxicological analysis indicate that Mr Willis had been drinking alcohol.

[2022] WACOR 3 recording asking his ex-wife to sit down, have a cup of tea and “work things out” with him. His ex-wife was heard saying that she did not want to work things out and that he had to leave as he was breaching the FVRO. It was only when his ex-wife began calling the police did Mr Willis return to his car and drive away. This was at about 1.40 am. Senior Constable Anthony Welch and Constable Carly Dennis-Watson then attended the ex-wife’s address.

Mr Willis’ ex-wife outlined to the two police officers what had taken place, including Mr Willis’ threat to kill himself. She also said that Mr Willis had previously made threats to kill himself and that he had never acted upon them.

Mr Willis’ ex-wife told the police officers that she believed he would not act upon his most recent threat.

Mr Willis’ ex-wife said that she did not wish to make a formal complaint and that she would think about supplying a statement to police later. As a result, her daughter’s mobile phone was not seized. However, the two police officers did listen to the audio recording that had been made.

Senior Constable Welch advised Mr Willis’ ex-wife that an Incident Report would be created and she could attend Kalgoorlie Police Station in the morning to make a complaint and provide a statement. At their request, Mr Willis’ ex-wife provided the police officers with Mr Willis’ address. She also advised he would more than likely not answer the door to them as he was aware she had contacted the police before he left.

Police attend Mr Willis’ address for the first time 13 Senior Constable Welch and Constable Dennis-Watson attended Mr Willis’ address at about 3.00 am on 8 March 2019. They saw that Mr Willis’ car was parked in the driveway. The house was in darkness and although 13 Exhibit 1, Tab 12, Statement of Senior Constable Anthony Welch dated 14 April 2019; Exhibit 1, Tab 13, Statement of Constable Carly Dennis-Watson dated 7 April 2019

[2022] WACOR 3 Senior Constable Welch loudly knocked on the front door several times, there was no answer. The two police officers then returned to the Kalgoorlie Police Station where they completed an Incident Report regarding the matter.

The subsequent welfare checks on 8 and 9 March 2019 At about 9.00 pm on 8 March 2019, Ms Stevenson contacted a police officer she knew at Kalgoorlie Police Station directly and requested that police do a welfare check on Mr Willis.

Subsequently, police officers conducted three welfare checks at Mr Willis’ address on 8 and 9 March 2019. It was not until the third welfare check during the afternoon of 9 March 2019 that police discovered Mr Willis’ body in a rear bedroom. His body was in the bedroom’s wardrobe and was partially suspended by a necktie, one end of which was attached to the wardrobe rail and the other around his neck.

Mr Willis’ body was cold to the touch and showed clear signs of rigor mortis.

Police called for an ambulance and attending ambulance officers confirmed that Mr Willis had died.

The manner in which the first attendance and subsequent welfare checks were conducted are dealt with in more detail later in this finding.

CAUSE AND MANNER OF DEATH Cause of death 14 Dr Dan Moss, a forensic pathologist, conducted a post mortem examination of Mr Willis’ body on 13 March 2019. Understandably, the most significant finding from this examination related to the ligature and the ligature mark to Mr Willis’ neck. Dr Moss noted that the ligature was tight around Mr Willis’ 14 Exhibit 1, Tab 5A-C, Supplementary Post Mortem Report, Post Mortem Report and Interim Post Mortem Report dated 13 March 2019; Exhibit 1, Tab 6, Toxicology Report dated 18 June 2019

[2022] WACOR 3 neck and that the linear striations within the ligature mark to Mr Willis’ neck was consistent with a fabric ligature.

The findings of the internal examination, and the balance of the external examination were unremarkable. Toxicological analysis of Mr Willis’ post mortem blood samples showed therapeutic levels of codeine and ibuprofen.

There was a blood alcohol level of 0.052% and in the urine sample at 0.075%.

However, these results ought to be interpreted with caution as the samples displayed evidence of putrefaction.

At the conclusion of his investigations, Dr Moss expressed the opinion that the cause of death was ligature compression of the neck (hanging).

I accept and adopt the conclusion expressed by Dr Moss as to the cause of Mr Willis’ death.

Manner of death I find Mr Willis’ death occurred by way of suicide when he tied a necktie around the wardrobe rail in his bedroom and then used it as a ligature around his neck.

Based on all the evidence before me, I am also able to find that Mr Willis’ death occurred when he returned to his house after he left his ex-wife’s address at about 1.40 am on 8 March 2019. I have reached that conclusion based on what Mr Willis was wearing when he was found,15 an observation made by Dr Moss during his external examination and what Mr Willis’ neighbours had told police.

The black t-shirt that Mr Willis was found wearing was a very distinctive one.

It had the word “Finisher” written on the front of it, which was surrounded by 15 Police took photographs of Mr Willis’ body in situ.

[2022] WACOR 3 a distinct pattern. Other details on the front of the shirt indicated it related to an Ironman triathlon. This t-shirt was the same one Mr Willis was wearing when he was interviewed by police on the evening of 7 March 2019.

His body was also found wearing a pale blue coloured pair of denim shorts.

This colour matched the shorts he was wearing in his police interview.

Mr Willis was wearing a white-faced watch with a gold band on his left wrist during his interview. He was wearing this watch when police found his body.

Dr Moss observed that on Mr Willis’ right hand was “some dried blood staining, particularly around the right index finger and left first web space.”16 This was most likely from the cut Mr Willis received to his hand when he climbed over the fence at his ex-wife’s house. I am able to conclude from Dr Moss’ observations that the blood had not been washed off.

The conclusion that Mr Willis died in the early hours of 8 March 2019 is also consistent with the outcome of door knocks conducted by police with Mr Willis’ neighbours on 9 March 2019. The occupants at 270B Collins St (the residence behind Mr Willis’ house) had not seen him for “a couple of days, which was out of character.”17 The occupant of 281 Collins St had not seen him since he returned home a couple of days ago and had seen his lights go out late on the night of 7 March 2019.18 I also note that Mr Willis’ ex-wife believed he was intoxicated when he was at her house on 8 March 2019 and it is common knowledge that people are less inhibited and more prone to make impulsive decisions when affected by alcohol.

16 Exhibit 1, Tab 5B, Post Mortem Report dated 13 March 2019, p.3 17 Exhibit 1, Tab 24, Memorandum of Constable Franceso Voglino (undated), p.2 18 Exhibit 1, Tab 24, Memorandum of Constable Franceso Voglino (undated), p.2

[2022] WACOR 3 Although I am not able to precisely determine when Mr Willis died, his death most likely occurred prior to the attendance of Senior Constable Welch and Constable Dennis-Watson in the early hours of 8 March 2019.

ISSUES RAISED BY THE EVIDENCE Police attendance to Mr Willis’ address at about 3.00 am on 8 March 2019 As outlined above, this attendance took place after police had been to the address of Mr Willis’ ex-wife. Although there had been no formal complaint made at that point in time, it is WAPF policy that the alleged perpetrator of a domestic incident is to be spoken to.19 As Senior Constable Welch explained, “if we had an unsubstantiated allegation of a domestic, we still are required to attend and attempt to speak with him. Prior to speaking with him, he would be cautioned and informed that we don’t have a formal complaint or statement.”20 The attendance, therefore, was not to arrest Mr Willis.

In those circumstances, I am satisfied that Senior Constable Welch and Constable Dennis-Watson were not required to do any more than what they did; namely, knock loudly on the front door several times.21 My reasons for reaching that conclusion are set out below.

First, the two police officers had already been told by Mr Willis’ ex-wife that he was not likely to open the door to police. 22 That was a very real possibility in light of the fact that Mr Willis had breached the conditions of the FVRO he had just been served with.23 19 ts 6.10.21 (Davis), p.116 20 ts 5.10.21 (Welch), p.23 21 ts 5.10.21 (Welch), p.25 22 ts 5.10.21 (Welch), p.25 23 ts 5.10.21 (Dennis-Watson), p.42

[2022] WACOR 3 Secondly, the police officers had been informed that Mr Willis was intoxicated.24 It was therefore not unreasonable for them to assume he had fallen into a deep sleep and had not heard their knocking.

Thirdly, Senior Constable Welch gave evidence that he did not have any concerns about Mr Willis’ welfare at that time, notwithstanding his recent threat to his ex-wife that he would kill himself. As he explained at the inquest, “because of the fact that she has actually said occasionally that he just makes threats, more to control the situation, of self-harm. He has never acted on it previously and she doesn’t believe that he’s likely to.”25 Fourthly, given that it was 3.00 am, Senior Constable Welch did not consider it appropriate to try and speak to Mr Willis’ neighbours.26 I agree with that, particularly given the fact Mr Willis was not an arrestable person at that stage and he had been sighted by his ex-wife about 90 minutes earlier.

I also note that Inspector Craig Davis, from the Goldfields District Office, was of the view that given the information available to the two police officers at the time, the welfare check would have been properly regarded as a very low risk.27 In a section titled “Risk Factors” on the Incident Report completed by Senior Constable Welch and Constable Dennis-Watson, there was an entry next to “Mental Health” that read “Yes POI28 Undiagnosed mental health”.29 Senior Constable Welch had no recollection whether he or Constable Dennis-Watson had written the entries in the section titled “Risk Factors”.30 24 ts 5.10.21 (Dennis-Watson), p.42 25 ts 5.10.21 (Welch), p.26 26 ts 5.10.21 (Welch), p.26 27 ts 6.10.21 (Davis), p.113 28 Person of Interest 29 Exhibit 1, Tab 19E, WA Police Incident Report 080319 0140 13241 30 ts 5.10.21 (Welch), p.24

[2022] WACOR 3 Nevertheless, he agreed that this information would have been supplied by Mr Willis’ ex-wife.31 Request for a police welfare check by Ms Stevenson 32 On 6 March 2019, Ms Stevenson and Mr Willis talked and texted on their mobile phones throughout the day, as they usually did on a daily basis. On the morning of 7 March 2019, they exchanged text messages. On her way home from work that afternoon, Ms Stevenson called Mr Willis on his mobile phone, however he did not answer. She then sent him text messages at 7.30 pm, 8.20 pm and 8.55 pm on 7 March 2019 and received no replies.

It not surprising that Mr Willis did not answer his mobile phone or respond to these text messages. He had been arrested at about 4.45 pm and had not been released by police until after 9.00 pm.

After being unable to contact Mr Willis the next day, Ms Stevenson contacted First Class Constable Preedy at Kalgoorlie Police Station, whom she knew from when they were both attached to Murdoch Police Station. After First Class Constable Preedy missed Ms Stevenson’s first call and she then missed his returned call, they eventually spoke to each other just before 9.00 pm on 8 March 2019. By this stage, Ms Stevenson was very concerned that she had not heard from Mr Willis. As a result of their conversation, First Class Constable Preedy completed the following CAD33 Job, for police from Kalgoorlie Police Station to attend Mr Willis’ address to check on him:34

CALLER IS AN OFF DUTY MEMBER OF POLICE CALLER REQUESTING POLICE CHECK ON SHAUN ANDREW WILLIS, DOB: 8/1/1965. CALLER HASN’T HEARD FROM 31 ts 5.10.21 (Welch), p.25; I accept that this information would have come from Mr Willis’ ex-wife as there is a similar passage in her statement, “I was aware that Shaun had issues with his mental health but to my knowledge was never properly diagnosed by a doctor.”: Exhibit 1, Tab 9, Statement of Janelle Willis dated 9 March 2019, p.1 32 Exhibit 1, Tab 10, Statement of Amanda Stevenson dated 25 April 2019; Exhibit 1, Tab 14, Statement of First Class Constable Dean Preedy dated 21 March 2019; ts 5.10.21 (Preedy), pp.47-62 33 Acronym for Computer Aided Dispatch. The CAD system is the central system used by the WAPF where all tasking is recorded, allocated, managed and monitored.

34 Exhibit 1, Tab 15, CAD Incident Report – Running Sheet, p.1

[2022] WACOR 3 WILLIS SINCE YESTERDAY MORNING AND ISN’T RETURNING ANY OF HER PHONE CALLS. SHE HAS HEARD VIA WILLIS’ FATHER THAT HE MAY HAVE BEEN IN A BIT OF TROUBLE IN RELATION TO HIS EX-PARTNER. CALLER WOULD LIKE POLICE TO CHECK ON WILLIS AND HAVE HIM CALL HER IF HE IS OK.

Shortly after that, First Class Constable Preedy added to the CAD system the mobile phone details for Ms Stevenson. Via the CAD system, he also advised the police officers tasked with the welfare check that during the previous evening, Mr Willis had been charged with aggravated common assault and released on bail.35 First Class Constable Preedy expected that the welfare check would have included a door knock, conversations with neighbours and a call on Mr Willis’ mobile phone which could be accessed from IMS.36 First welfare check at Mr Willis’ address At 9.13 pm on 8 March 2019, Senior Constable Lorraine Dempsey and Constable Domenic De Carvalho were tasked to attend Mr Willis’ address in relation to the welfare check that had been requested.37 Coincidentally, these two police officers had attended Mr Willis’ address on 5 March 2019 to serve the FVRO that was eventually served on him on 7 March 2019. There was no response to their knocks on the locked front security door and side window on that earlier occasion.38 The two police officers arrived at Mr Willis’ address at about 9.15 pm to carry out the welfare check.39 They observed Mr Willis’ utility parked in the carport and its bonnet was cold to the touch. The house appeared to be in complete darkness and the front security door was locked, as was the side gate. Neither 35 Exhibit 1, Tab 15, CAD Incident Report – Running Sheet, p.1 36 ts 5.10.21 (Preedy), p.54 37 Exhibit 1, Tab 15, CAD Incident Report – Running Sheet, p.1 38 Exhibit 1, Tab 22, Memorandum of Senior Constable Dempsey (unsigned), pp.1-2 39 Exhibit 1, Tab 22, Memorandum of Senior Constable Dempsey (unsigned), p.2

[2022] WACOR 3 police officer could see into the house from a side window as the curtains and/or blinds were closed.

As they had done on the last occasion, the two police officers loudly knocked several times on the front door and the side window. They could not detect any noise or movement from inside the house, and although it was a fairly warm night there was no sound coming from the air-conditioning unit.40 As to whether entry should be forced into the premises, Senior Constable Dempsey was of the view:41 Based on the information we were provided with at the time I believed justification did not exist. Willis was not known to the Police to have any previous warnings for self-harm and no information in relation to self-harm or mention of self-harm was mentioned in relation to the CAD job I was attending.

In her evidence at the inquest, Senior Constable Dempsey said she had formed the belief on the night that as Mr Willis could still be wanted for questioning by police, he may have been avoiding them.42 She also said that she and Constable De Carvalho had not been told Mr Willis had possible undiagnosed mental health issues.43 In her view, justification to force an entry would have only been established if she had a reasonable belief Mr Willis was inside the house and that his life was in danger or he was in danger of serious harm.44 Constable De Carvalho also said the decision was made not to force entry into the house, “as there were no immediate welfare concerns for Willis based on the information on hand.”45 Senior Constable Dempsey did not recall speaking to any neighbours. She thought she and Constable De Carvalho had made a decision that there was no 40 Exhibit 1, Tab 22, Memorandum of Senior Constable Dempsey (unsigned), p.2 41 Exhibit 1, Tab 22, Memorandum of Senior Constable Dempsey (unsigned), p.2 42 ts 5.10.21 (Dempsey), p.67 43 ts 5.10.21 (Dempsey), p.67 44 ts 5.10.21 (Dempsey), p.67 45 Exhibit 1, Tab 23, Memorandum of Constable Dom De Carvalho dated 5 May 2019, p.2

[2022] WACOR 3 need to knock on the neighbours’ doors.46 Upon reflection, she accepted that speaking to neighbours “would have been an ideal course to take.”47 When Senior Constable Dempsey was asked whether a simple knock on the door to a neighbour should have been done, she responded, “…just based on what we had at the time, I just believe at the time we had done everything that we were justified to do, but I agree that I should have knocked on a door; I don’t understand why I didn’t, if I haven’t”.48 There is no evidence before me that the door of any neighbour was knocked during this welfare check.

In my view, it was not too late in the evening for these two police officers to conduct door knocks with the neighbours of Mr Willis. With the considerable advantage of hindsight, that should have been done. However, I would be incorrectly inserting hindsight bias if I was to criticise these two police officers for their failure to do so. I also note that checking with neighbours was not required by WAPF policy at the time.

Senior Constable Dempsey gave evidence at the inquest that when she now does welfare checks at addresses and no one responds to her knocking on the door, she leaves a contact card with a note as to why police have attended.49 Senior Constable Dempsey completed the outcome of their welfare check on the CAD system, noting that Mr Willis’ vehicle was in the driveway, that there were no lights on in the house and nobody answered the door after knocking multiple times.50 46 ts 5.10.21 (Dempsey), p.68 47 ts 5.10.21 (Dempsey), p.72 48 ts 5.10.21 (Dempsey), pp.73-74 49 ts 5.10.21 (Dempsey), p.71 50 Exhibit 1, Tab 15, CAD Incident Report – Running Sheet, p.2

[2022] WACOR 3 Unfortunately, Ms Stevenson was not notified of the outcome of this welfare check. Senior Constable Dempsey understood that “the supervisor on dispatch was liaising with the family.”51 Ms Stevenson’s contact with police after the first welfare check At about 10.50 pm on 8 March 2019, Ms Stevenson contacted the WAPF Police Assistance Centre (PAC) on its telephone number, 131 444. She explained why she was calling and requested an update. She was told someone would ring her back.52 The CAD entry for this telephone call was made at 10.50 pm on 8 March 2019.

That entry read, “Stevenson has called back and is requesting an update on if and when police may be attending. Stevenson is worried as he [i.e. Mr Willis] is still not responding to any texts and she is worried”.53 Eight minutes later, at 10.58 pm, the following CAD entry is recorded: “All Kalgoorlie vehicles currently tied up with higher priority tasking”.

At 11.06 pm, there is another CAD entry that said that as Mr Willis was wanted for questioning for the offence of breaching a FVRO, he is likely to be avoiding police. This entry also stated that this information is not to be disseminated to “the third party” (i.e Ms Stevenson).54 Several hours later, at 3.11 am on 9 March 2019, a CAD entry read that the welfare check was: “To be reattended by day shift”.55 The update that Ms Stevenson requested (a request which I find to be entirely reasonable) was not provided. I find that the police officer responsible for that 51 ts 5.10.21 (Dempsey), p.69 52 Exhibit 1, Tab 10, Statement of Amanda Stevenson dated 25 April 2019, p.5 53 Exhibit 1, Tab 15, CAD Incident Report – Running Sheet, p.2 54 Exhibit 1, Tab 15, CAD Incident Report – Running Sheet, p.1 55 Exhibit 1, Tab 15, CAD Incident Report – Running Sheet, p.1

[2022] WACOR 3 failure would have been the on-duty shift sergeant at Kalgoorlie Police Station.

Even if the view of the shift sergeant was that it was too late for a call to be made to Ms Stevenson, then efforts should have been made to ensure she was contacted the next morning by the next on-duty shift sergeant. There is no CAD entry to reflect that was done.

Second welfare check at Mr Willis’ address 56 Although the welfare check was assigned to two police officers at 7.36 am on 9 March 2019, those police officers were subsequently cleared from completing the welfare check at 7.58 am.57 Presumably, this was because of a more urgent task allocated to them.

The task was then assigned to Senior Constable Rory Anton and Constable Francesco Voglino at 8.37 am.58 Constable Voglino was relatively inexperienced at the time, having either nearly completed or just completed his 18 month period as a probationary constable.59 The two police officers arrived at Mr Willis’ address at about 8.51 am. As had been noted by police on the two previous visits to the property, Mr Willis’ utility was parked in the car port and another car belonging to his housemate was also parked at the front of the address. Senior Constable Anton contacted the Kalgoorlie Police Station via police radio in an attempt to obtain a mobile phone number for the housemate, however the WAPF Incident Management System (IMS) had no number listed for him.

The two police officers knocked several times on the front door and window of the residence without any answer. All curtain and blinds were drawn so they 56 Exhibit 1, Tab 21, Memorandum of Senior Constable Rory Anton dated 1 May 2019; Exhibit 1, Tab 24, Memorandum of Constable Francesco Voglino (undated) 57 Exhibit 1, Tab 15, CAD Incident Report – Running Sheet, pp.3-4 58 Exhibit 1, Tab 15, CAD Incident Report – Running Sheet, p.4 59 ts 6.10.21 (Voglino), p.84

[2022] WACOR 3 could not see into the property and the side gate to the property was still padlocked.

Based on the limited information available to them at the time, neither police officer formed a suspicion that anything untoward had taken place inside the address and therefore, there was no justification to force entry. Senior Constable Anton also took into account the two vehicles at the property to reach that conclusion. After summarising the outcome of their attendance with a CAD entry, the two police officers completed this particular job at about 8.54 am.

In his evidence at the inquest, Constable Voglino could not recall if they had Mr Willis’ mobile phone number.60 He also said that it did not occur to him to knock on neighbours’ doors. After stating that he did not see any real reason at the time to do that, Constable Voglino conceded that, “I can’t offer any other explanation for that.”61 Neither he nor Senior Constable Anton left a card at the front door of the residence.62 Constable Voglino testified at the inquest there were multiple innocent reasons why Mr Willis was not answering the door, for example, that he had to gone somewhere else and was not at the address.63 Constable Voglino was then asked the following question:64 So you thought effectively that there’s no cause for concern because there are these other explanations as to why he might not be answering the door? --- I did, yes, you know, have other – obviously, you know, there was [sic] other reasons why he may not be answering the door and in the initial job there wasn’t really any concerns raised for his welfare, other than he wasn’t answering the phone to the caller from Perth.

60 ts 6.10.21 (Voglino), p.81 61 ts 6.10.21 (Voglino), p.83 62 ts 6.10.21 (Voglino), p.86 63 ts 6.10.21 (Voglino), pp.87-88 64 ts 6.10.21 (Voglino), p.88

[2022] WACOR 3 Inspector Davis was of the view that door knocks of Mr Willis’ neighbours should have been undertaken at this welfare check.65 Inspector Davis was also of the view that if these door knocks did not provide further information then further investigations could have been undertaken at the police station, such as contacting Ms Stevenson, the ex-wife or even calling Mr Willis directly.66 It is noted that Inspector Davis expressed these views with the benefit of hindsight and on condition that other tasks had not been prioritised for the two police officers.

I agree with Inspector Davis’ view that some door knocking of neighbours could have quite easily been undertaken. There is no explanation as to why it was not done, other than it was not deemed necessary. Although I am satisfied that Mr Willis had died by this time, it was unfortunate that First Constable Anton and Constable Voglino did not do something more than what they did. I note that their efforts essentially replicated those efforts by the two police officers on the previous night. It would have been appropriate in those circumstance to pursue other lines of enquiry, the most obvious being doorknocks with the neighbours of Mr Willis.

Ms Stevenson’s contact with police after the second welfare check 67 Unfortunately, Ms Stevenson was not advised of the outcome of the second welfare check. At 1.40 pm on 9 March 2019, she rang the PAC again wanting to know what had happened. The CAD entry for that call noted Ms Stevenson was “demanding update on welfare check” and that she was “irate and wanting to know what is going on”.68 I can fully appreciate why Ms Stevenson would be annoyed that she had not been contacted.

65 ts 6.10.21 (Davis), p.155 66 ts 6.10.21 (Davis), p.117 67 Exhibit 1, Tab 10, Statement of Amanda Stevenson dated 25 April 2019 68 Exhibit 1, Tab 15, CAD Incident Report – Running Sheet, p.5

[2022] WACOR 3 By about 3.00 pm on 9 March 2019, police had still not updated Ms Stevenson regarding the welfare checks on Mr Willis. As a result of that, she attended the Cannington Police Station and demanded to know whether Mr Willis was okay or not.

During the inquest, Ms Stevenson (who attended both days of the inquest) raised with Counsel Assisting that when she attended the Cannington Police Station, she made it clear that she would refuse to leave until some action was taken.69 In light of the fact that about 20 minutes after her attendance the task was allocated to police officers at Kalgoorlie, I am satisfied that the stance taken by Ms Stevenson would have been responsible for the quick dispatching of this task.

Final welfare check at Mr Willis’ address 70 At 3.20 pm Constable Voglino and Constable Liam Trimmer were tasked to carry out another welfare check at Mr Willis’ address.71 These two police officers arrived at the address at 3.36 pm. A CAD entry recorded that the mobile number IMS had for Mr Willis was called by one of these police officers and was engaged.72 This is the only record of any attempt by police to contact Mr Willis on his mobile phone. If this was, in fact, the first attempt to call Mr Willis’ mobile phone, that is somewhat concerning as it was more than 18 hours after Ms Stevenson had requested the welfare check.

The two police officers knocked on the front door and front window a number of times and received no response. Constable Voglino observed the same two cars at the address that he had seen earlier that morning. On this occasion, he 69 ts 6.10.21 (Counsel Assisting), p.101 70 Exhibit 1, Tab 20, Statement of Constable Liam Trimmer (undated and unsigned); Exhibit, Tab 24, Memorandum of Constable Francesco Voglino (undated) 71 Exhibit 1, Tab 15, CAD Incident Report – Running Sheet, p.4 72 Exhibit 1, Tab 15, CAD Incident Report – Running Sheet, p.6

[2022] WACOR 3 found that the door of Mr Willis’ utility was unlocked. He had a look through the vehicle and nothing of note was located. The police officers then attended 270B Collin St and spoke with the occupants. As already outlined above, the occupants stated they had not seen Mr Willis for a couple of days and that this was out of character. The occupant of 281 Collins St then actually approached the police officers and, as already outlined, said she had not seen Mr Willis since he returned home on 7 March 2019 and seen his lights go out late on that night. This neighbour also commented that it was unusual for Mr Willis to go out and leave his car.

The two police officers then decided to jump the padlocked side gate to gain access to the rear yard. They looked through a small gap in the blinds and saw what they later found to be Mr Willis’ mobile phone and wallet on the kitchen bench.

Given that it was unusual for someone to leave their house without their wallet and phone, the level of the police officers’ concerns regarding Mr Willis’ welfare had increased.73 They contacted their shift sergeant and received permission to force entry. First Class Constable Joel Corrie then attended with equipment to assist with entry into the house.

Access to the house was achieved at about 4.30 pm and a search located Mr Willis’ body in a rear bedroom.

Not surprisingly, I am satisfied with the efforts made by police during the final welfare check. They spoke to neighbours, they accessed the rear yard and their concerns for Mr Willis’ wellbeing were raised when they observed his wallet and mobile phone on the kitchen bench. However, there was nothing preventing these steps being undertaken during the second welfare check. Had 73 ts 6.10.21 (Voglino), p.92

[2022] WACOR 3 these same measures been undertaken then, Mr Willis’ body would have been located earlier than it was.

Failure by police to update Ms Stevenson Ms Stevenson was not informed of the outcome of any welfare checks until she was notified of Mr Willis’ death sometime after 4.30 pm on 9 March 2019.

That was unacceptable. I fully agree with Inspector Davis’ concession that, “we were poor and neglectful for not contacting Ms Stevenson… We should have called Ms Stevenson at the night [of 8 March 2019]. We should have called her the next day. We should have called her that afternoon [following Ms Stevenson’s call at 1.40 pm]”.74 I completely agree with Inspector Davis’ summary. There are transcripts of the calls made by Ms Stevenson to the PAC at 10.48 pm on 8 March 2019, 8.37 am on 9 March 2019 and at 1.40 pm on 9 March 2019.75 On each occasion, the operators who answered her calls said they would put in a request that she be contacted. The operators are certainly not to blame for the fact that no one contacted Ms Stevenson. All their entries into the CAD system make it clear that Ms Stevenson wanted to know what was going on.76 A WAPF internal investigation was undertaken with respect to the failure to provide Ms Stevenson with any updates. This investigation found that the relevant shift supervisor at Kalgoorlie Police Station had been neglectful in failing to contact Ms Stevenson and advise her of the progress regarding the welfare checks.77 I agree with that finding.

74 ts 6.10.21 (Davis), p.112 75 Exhibit 1, Tab 16, Transcript of PAC calls by Ms Stevenson on 8 and 9 March 2019 76 Exhibit 1, Tab 15, CAD Incident Report – Running Sheet, pp.2,4,5 77 Exhibit 1, Tab 19I, WA Police Internal Affairs Investigation COP 2019-0103

[2022] WACOR 3 Adequacy of existing WAPF policies regarding welfare checks The WAPF generates over 60,000 welfare checks annually. In 2019/2020 and 2020/2021 there were, in fact, over 64,000 tasks created for welfare checks for each of those years.78 Annually, there are over 4,500 missing person/absconder tasks.

A welfare check task has a job code number 48 within the CAD system.

Welfare checks generally incorporate reports from the public where concern is held for the health and safety of an individual. Common examples of matters requiring welfare checks include someone behaving oddly in public, a loved one not answering their phone or a voluntary mental health patient leaving a facility.79 In contrast, a missing person/absconder task has a code 49 and is when a person’s whereabouts is unknown and there is a genuine concern for their health and safety (e.g. a dementia patient has wandered off, a mental health patient has left a hospital after threatening self-harm or an involuntary patient has not returned from day release).80 The standard operating procedures for police responses to these tasks are in WAPF Policy CR-10.00 Missing and At Risk Persons.81 A common thread in the evidence of those police officers called at the inquest is that the circumstances of a welfare check differ markedly from one to the next. As Assistant Commissioner Joanne McCabe described it, “the welfare check bucket, so to speak is … quite large and broad”.82 78 Exhibit 1, Tab 25, Report of Assistant Commission Joanne McCabe dated 30 September 2021, p.1 79 Exhibit 1, Tab 25, Report of Assistant Commission Joanne McCabe dated 30 September 2021, p.2 80 Exhibit 1, Tab 25, Report of Assistant Commission Joanne McCabe dated 30 September 2021, p.2 81 Exhibit 1, Tab 19J, CR-10.00 Missing and At Risk Persons 82 ts 6.10.21 (McCabe), p.133

[2022] WACOR 3 The consensus from the frontline police officers who gave evidence was that because of the wide ranging aspects of welfare checks, the policies governing this area of policing cannot be detailed. As Inspector Davis said:83 It’s not detailed. It is brief but it needs to be brief because the situation we’re talking about today is different from any other situation I have dealt with, and I have dealt with probably – literally thousands of welfare checks myself. We have, in the last 12 months in the Goldfields, we had 3,300. So about nine a day come to the police station in regards to welfare checks, missing persons and absconder checks.

So it’s huge. So it needs to be broad because there is a huge difference between the spectrums of the welfare checks that we get. So, look, it’s great to have prompts [for] how we do things but it’s different because our job is so different, and everyday is different and every situation is different. You cannot pigeonhole any situation. This situation that we’re talking about is different to any other situation in some way.

Senior Constable Dempsey described the existing policies in this way:84 I think they are detailed enough. These – a lot of these jobs, they’re just so different and I think it would be difficult for them to construct policy that would relate to and encompass all of it; it’s just so – they’re just so different.

Constable Corrie expressed a similar view, testifying “it’s difficult to outline things in policy because each situation is different”.85 He agreed that the best way to learn how to carry out a proper welfare check was “on the job” training.86 In October 2020, the WAPF Operations Support Folio commenced a holistic review of the current state of police job codes, including welfare checks and missing persons/absconders.87 One of the review team’s findings was illustrated by the evidence at the inquest. This finding was that “The current decision-making model for 83 ts 6.10.21 (Davis), p.123 84 ts 5.10.21 (Dempsey), p.70 85 ts 6.10.21 (Corrie), p.99 86 ts 6.10.21 (Corrie), p.100 87 Exhibit 1, Tab 25, Report of Assistant Commissioner Joanne McCabe dated 30 September 2021, p.2

[2022] WACOR 3 frontline officers was subjective and failed to achieve consistency.”88 The WAPF Corporate Board endorsed this and the other findings and the review was progressed to a dedicated project team (the team). The team was established in February 2021.

On 26 May 2021, seven options were presented by the team to the WAPF Corporate Board (the Board) for endorsement. The Board provided in principle endorsement for them to proceed, on condition that there be wide internal consultation before the final decisions were brought back to the Board for approval. Subsequently, on 2 August 2021, the project commenced the design phase and was formally handed over to the State Intelligence Portfolio.

I have carefully read Assistant Commissioner McCabe’s report, and I endorse the progress made since October 2020. I am particularly impressed with the new policy being drafted that removes the term “Persons at Risk”, and which now provides clarity for police response and investigation into three categories; namely “absent person”, “missing person” and “lost person”. With these new categories, Mr Willis would have been classified as an “absent person”.89 Another encouraging development is the use of technology that has created an application named “Hey Sarge”. As explained by Assistant Commissioner McCabe:90 So we have what is known as our Hey Sarge application which sits within our mobile phones now and we’re hoping to build an application that sits within that so that when our officers are attending or responding to jobs where there is welfare concerns for people, regardless of what scale they are, we’re hoping there will be a series of pretty specific early questions that will help them identify whether somebody may be missing, somebody may be absent, someone may be lost and provide some recommendations on the next steps for them. And we’re just building that risk matrix at the moment because there are a lot of things that we know are 88 Exhibit 1, Tab 25, Report of Assistant Commissioner Joanne McCabe dated 30 September 2021, p.3 89 ts 6.10.21 (McCabe), p.138 90 ts 6. 10.21 (McCabe), p.136

[2022] WACOR 3 indicators. They are not – might not be at the forefront of our officers’ minds’ but they’re indicators that - you know, that the [person] might pose a higher risk to selfharm to themselves or others. So we’re just building that process now.

Frontline officers now have access to more information regarding a task than they did in March 2019. This is through software that the WAPF has made available on police officers’ mobile phones.91 They now have the opportunity of viewing the contents of relevant Incident Reports if they are “on the road” performing a task. This would have been useful for these welfare checks as the earlier Incident Report completed by Senor Constable Welch and Constable Dennis-Watson had the entry that Mr Willis had “undiagnosed” mental health issues.92 The system that existed in March 2019 would have required any relevant information from an Incident Report to be entered into the CAD job before a frontline officer could access it. That job was the responsibility of the sergeant overseeing CAD tasks.93 Alternatively, if those entries had not been made (as was the case here), a police officer tasked with the welfare check would have had to make a call to the police station and get someone to access it from there.94 As Constable Voglino testified, if the CAD job had an entry that Mr Willis had undiagnosed mental health issues, that would have elevated his concern in carrying out his welfare checks.95 91 ts 6.10.21 (Voglino), p.94 92 Exhibit 1, Tab 19E, WA Police Incident Report 080319 0140 13241, p.3 93 ts 6.10.21 (Davis), pp.110-111 94 ts 6.10.21 (Voglino), p.95 95 ts 6.10.21 (Voglino), p.95

[2022] WACOR 3 RECOMMENDATIONS The leaving of a calling card No calling card was left by any police officer with respect to their attendances at Mr Willis’ home.

I accept Inspector Davis’ evidence that there will be occasions when police do not necessarily want the occupant of a house to know that they have attended.

For example, if police are attending in order to arrest a suspect.96 In those circumstances, it would not be prudent for police to leave any evidence that they have attended.

However, when the purpose of the attendance is confined to a welfare check, there is considerable merit in leaving a calling card (with information as to the reason for the police attendance) at the front door should there be no one at home or the person, for whatever reason, does not want to answer the door.

When the card has been inserted between a locked door and the door frame, three benefits immediately come to mind as to the effectiveness of this course of action.

The first is that if the person was not actually home. Upon returning home, they would see the card and then, hopefully, follow the instructions written on the card. A second benefit would be if the person, for whatever reason, does not want to contact the police. If the card has been dislodged by the door being unlocked, then a subsequent police attendance would become aware that the door has been opened. The third benefit is if the card has remained in place for an unexpected length of time. That would assist police in determining what course of action should be taken.

96 ts 6.10.21 (Davis), p.99

[2022] WACOR 3 Having heard from several of the frontline police officers involved in this matter that their practice is now to leave a card when conducting welfare checks, I am of the view that WAPF policy should require the leaving of a card by police attending a residence for a welfare check whenever their door knocks are not answered. This card should contain the necessary information for the person to make contact with police and the reason why.

Inspector Davis agreed that this requirement for a task that “was purely a welfare check” was entirely appropriate and that “There is no reason not to” introduce it as a policy.97 It would seem that this policy could easily be incorporated into the “Hey Sarge” application as a recommendation for police to take.

Recommendation No. 1 When attending the known address of a person the subject of a welfare check, police officers who have not had their door knocks answered should leave a card at the front door explaining the purpose of their attendance and their contact details.

Speaking to neighbours The circumstances of this case highlighted the fact that neighbours can have critical information regarding the whereabouts of a person who is the subject of a welfare check. The information Mr Willis’ neighbours provided to police dispelled the modern day notion that people do not know their neighbours and their daily activities.

97 ts 6.10.21 (Davis), pp.116-117

[2022] WACOR 3 Just like the leaving of the calling card, frontline police officers who testified at the inquest now routinely check with neighbours as to the whereabouts of a person who is the subject of a welfare check and who has not been located. It is my view that this is another action police officers should always carry out when undertaking a welfare check. The only qualification I would place on performing this action is if it is inappropriate to do so. One obvious example of that would be if the welfare check is performed late at night. Once again, it would seem that this policy could be included in the ‘Hey Sarge’ application.

Recommendation No. 2 When attending the known address of a person the subject of a welfare check, police officers who have not had their door knocks answered should, if it is appropriate to do so, speak to neighbours to ascertain the whereabouts of the person.

CONCLUSION At the time he took his life, Mr Willis was a troubled man. Notwithstanding having Ms Stevenson as his partner, the volatile relationship he had with his ex-wife had continued following their separation. After his uninvited visit to her house on 26 February 2019, his ex-wife made an assault allegation which led to police advising him on the evening of 7 March 2019 that he would be charged with aggravated common assault. On top of that, he was also served with an FVRO at the same time. Notwithstanding his calm demeanour in the presence of police on 7 March 2019, I am of the view that Mr Willis has highly stressed by the time he had arrived home from the police station.

[2022] WACOR 3 Once home, he consumed a quantity of alcohol before driving to his ex-wife’s residence. In doing so, he had breached the FVRO that only hours earlier had been served on him. He only left that address when his ex-wife, who had (quite properly) refused his requests “to work things out”, began calling the police.

Mr Willis returned home, and still effected by the alcohol he had consumed, he made the impulsive decision to end his life.

Although he left no note explaining his actions, Mr Willis had threatened to kill himself when he attended his ex-wife’s house for the last time. I understand why his ex-wife did not regard this threat as a serious one as Mr Willis had made similar threats in the past without attempting to act upon them.

Tragically, unlike the other times, the threat on this occasion was carried out.

Although it involves a degree of speculation, I am of the view that Ms Stevenson’s observations regarding the reasons why Mr Willis made the decision to end his life have some merit:98 … I think that it all just got too much to him, if an incident did occur and the children were present, he would have hated himself for exposing his children to that behaviour, if police were involved and he was dealt with by police this again would have got on top of him, he would have been worried about the impact on me professionally and our relationship, with everything going on he would have felt backed into a corner.

In this finding, I have examined the actions of police officers following the request for a welfare check of Mr Willis by Ms Stevenson. Although more could have been done, particularly with the second welfare check, I have not made adverse findings with respect to any police officer involved in this matter. The only criticism I have made was the failure, despite her repeated requests, to update Ms Stevenson with the progress of the welfare checks. I note that an internal investigation by the WAPF has found that the relevant 98 Exhibit 1, Tab 10, Statement of Amanda Stevenson dated 25 April 2019, p.11

[2022] WACOR 3 police officer responsible for this failure was neglectful of his duties in that regard.

I will also make it clear that no action by any police officer either caused or contributed to Mr Willis’ death. I have found that Mr Willis had already died prior to the first welfare check on the evening of 8 March 2019 and, in all likelihood, he had already committed suicide before the first attendance by police at 3.00 am on 8 March 2019.

I am satisfied with the changes that are in the process of being implemented by the WAPF with respect to its policies regarding absent and missing persons. I have, nevertheless, made two recommendations aimed at addressing the issues I have identified during the inquest. It is my hope that these recommendations will provide some small consolation to Mr Willis’ family and his partner.

I convey my condolences to Mr Willis’ family and loved ones, particularly his daughter and his son, for their sad loss.

PJ Urquhart Coroner 17 January 2022