Inquest into the Death of Ashley Dean FILDES

[2023] WACOR 38 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON, DEPUTY STATE CORONER DELIVERED : 20 OCTOBER 2023 FILE NO/S : CORC 19 of 2020

DECEASED : FILDES, ASHLEY DEAN Catchwords: Nil Legislation: Nil Counsel Appearing: Mr W Stops assisted the Coroner.

Mr T Bishop (SSO) appeared on behalf of the East Metropolitan Health Service and the WA Police Force.

Case(s) referred to in decision(s): Nil

[2023] WACOR 38 Coroners Act 1996 (Section 26(1))

RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Deputy State Coroner, having investigated the death of Ashley Dean FILDES with an inquest held at Perth Coroners Court, Court 85, Central Law Courts, 501 Hay Street, Perth, on 29 May 2023 to 31 May 2023, find that the identity of the deceased person was Ashley Dean FILDES and that death occurred on 1 May 2020 at South Hedland Shopping Centre, Throssell Road, South Hedland, from gunshot injuries in the following circumstances:

TABLE OF CONTENTS SUPPRESSION ORDER There be no reporting or publication of any document or evidence that would reveal the detail of police policies and standard operating procedures, tactics, or training methods in relation to the use of force, including, but not limited to, firearms and Taser Conducted Energy Weapon (CEW).

[2023] WACOR 38 INTRODUCTION

1. Ashley Fildes was fatally shot by police on 1 May 2020 in the South Hedland Shopping Centre. Ashley was normally a gentle person, but on this day he was in an acute psychotic state and had stabbed a number of strangers without warning. Two police officers, who happened to be in the area, saw Ashley running through the shopping centre armed with a knife and tried to stop him. Ashley was tasered by police without effect. He then assaulted one of the police officers before he turned towards the other police officer and threatened him with the knife. The second officer drew his firearm and, when Ashley did not respond to commands to drop the knife, he was shot three times. Despite efforts by the same police officer and others, to provide first aid, Ashley died shortly afterwards from his injuries.

2. Due to the involvement of police officers in Ashley’s death, an inquest was mandatory pursuant to s 22(1)(b) of the Coroners Act 1996 (WA). I held an inquest from 29 to 31 May 2023. The inquest was held in Perth, rather than South Hedland, as most of the witnesses and Ashley’s parents and former wife were based in Perth. The inquest hearing was also streamed to the South Hedland Courthouse, to allow members of the local community in South Hedland who were affected by this tragic and traumatic event to also participate in the inquest process.

3. The inquest heard evidence from police officers who investigated this matter after Ashley’s death, as well as the two police officers directly involved in these sad events.

A number of Ashley’s work colleagues, who witnessed his sudden mental deterioration that day, were called to give evidence. In addition, some expert psychiatric evidence was provided to help me understand Ashley’s mental state at the time of his death and whether there were missed opportunities to manage his psychiatric care differently. Personal information about Ashley was provided by his parents and his former wife, who is also the mother of Ashley’s only child. The statements of the people who were stabbed by Ashley on the day were tendered in evidence, as there was no need to put them through the trauma of giving evidence in the circumstances.

4. At the conclusion of the inquest, I indicated that I would not be making any adverse comments in relation to the police officers who were involved in Ashley’s death or any of the health practitioners. While I have no doubt that everyone involved wishes there could have been a different outcome for Ashley, the events that occurred were not anyone’s fault and no reasonable steps to prevent Ashley’s death were missed. At the time he was discharged from the Eudoria Street Centre, Ashley was in remission and the expert evidence before me indicates there was no basis to move him from voluntary to involuntary patient status and force him to keep taking his depot medication. Whilst his relapse into psychosis was predictable after he stopped taking his medication, the suddenness of his relapse was unusual and his violence towards others was totally out of character and unexpected. The two police officers who were involved in Ashley’s final moments were faced with a very difficult and dynamic situation. They tried non-lethal ways to stop Ashley, but unfortunately they were ineffective for a number of reasons. The officer who then fatally shot Ashley was left with no choice but to use lethal force to save his own life, as well as to preserve the safety of his colleague and other members of the public.

[2023] WACOR 38 BACKGROUND

5. Ashley was born on 4 January 1986 to his parents, Lester and Jennifer. Ashley was followed by his younger brother Nathan and sister Emma in the next two years. The children grew up in Thornlie. Ashley was always a happy person and a good student who grew up in a loving home with a structured home life. Ashley liked to fix things and following graduation, he transitioned straight into work as a tradesman. Ashley did a bricklaying course with his brother and eventually got into asphalting work.1

6. Ashley moved out of home at 18 years of age and lived with some friends at a house in Maddington. He met and started a relationship with his future wife Tanya in 2009, while living there. The couple lived in a few different places in Perth before they moved to Nullagine so that Tanya could commence her first permanent position in her teaching career. Ashley and Tanya married in 2011 and remained living in Nullagine for a few more years. Ashley and Tanya’s daughter, Selena, was born in August 2013, while they were still based in Nullagine. Tanya took maternity leave then returned to work full time. They had limited childcare options, so Ashley quit his full-time job in the mining industry in order to help care for their young daughter.2

7. Ashley and Tanya would return with their daughter regularly to Perth for Christmas and holidays and it appeared to Ashley’s parents that they were a close and happy little family. However, they later came to learn that the couple were struggling at this time and fighting often, although they did not share their troubles with their broader family.

Tanya said they had often slept in separate rooms as their daughter was up a lot during the night and when Tanya went back to full-time work, they began to see even less of each other as they would ‘tag team’ as carers of their daughter. Ashley and Tanya also had very different interests, which became more apparent over time. In particular, Ashley’s developing interest in religion.3

8. Ashley rekindled his Christian faith through contact with a neighbour in Nullagine who was a chaplain. Ashley had grown up in an Anglican household but stopped active involvement in the Church in his teenage years. Ashley reportedly played Christian music while working out in the heat and said he felt really inspired by his new found faith, although his renewed enthusiasm for religion was not shared by his wife, who considered herself a non-practising Christian.4

9. In about 2017, Tanya was transferred as part of her teaching career and the family of three happily made the move to her new post in Onslow. They enjoyed being near the ocean and Ashley bought a boat with his brother as he loved fishing and being outdoors. There was a day care centre in Onslow so Ashley was able to go back to work and they bought an investment property in Wandi.5

10. Unfortunately, during their time in Onslow, the couple began to suffer more significant marital difficulties. Tanya noticed concerning changes in Ashley’s 1 Exhibit 1, Tab 37 and Tab 38 and Tab 49.

2 Exhibit 1, Tab 37 and Tab 38.

3 Exhibit 1, Tab 37 and Tab 38.

4 Exhibit 1, Tab 37 and Tab 38.

5 Exhibit 1, Tab 38.

[2023] WACOR 38 behaviour due to his increasing religious focus and it eventually “created a divide that could not be fixed.”6 Tanya found out that Ashley was telling people that Tanya “needed to be saved”7 because she wasn’t part of the church. She spoke to Ashley and explained that it wasn’t for her and they didn’t discuss it again, but it drove a wedge between them.8

11. In October 2016, Ashley and Tanya formally separated when they moved back to Perth. Ashley moved in with his parents, who became aware for the first time that the marriage was in trouble. Tanya and Selena moved in with Tanya’s relative. Tanya encouraged Ashley to seek counselling in Perth as she felt he needed help, but it seems Ashley thought this was in order to work towards reconciling. Ashley did engage in counselling, as he thought it might save their marriage, but the relationship did not resume and they eventually divorced in December 2017. Ashley’s parents recalled Ashley was devastated by the failure of his marriage and he began to show early signs of depressive illness.9

12. Ashley and Tanya agreed to a childcare arrangement, which eventually worked out to Ashley having care of Selena every second weekend and one week of the school holidays. They reached this arrangement by mutual agreement, with the best interests of their daughter in mind. Ashley was said to be a caring, gentle father who enjoyed spending time with his daughter and doing activities with her. Ashley also remained close with the rest of his family, and his parents would help out with caring for their granddaughter when Ashley was busy with work.10

13. In April 2017, there was an incident following a family wedding and a misunderstanding about the childcare arrangement. Ashley refused to leave and was issued a 24-hour police order. There was no suggestion that Ashley was violent at the time, and he had never been violent during the marriage. It was just that he wouldn’t leave when requested.11 After that incident, Tanya and Ashley continued to share care of their daughter without incident. Tanya said that Selena always came home from her visits with Ashley in good spirits, happy and healthy.12

FIRST HOSPITAL ADMISSION

14. Ashley’s parents recalled that Ashley had “lost his balance”13 after his marriage ended but he still seemed to manage alright in 2017 and 2018.14 However, things worsened over time. Ashley became increasingly involved in spiritual worship, which was different to the Anglican faith he had grown up with and caused his parents some concern. Ashley told them that he was “trying to live in a spiritual world mentally”15 6 Exhibit 1, Tab 50, p. 1.

7 Exhibit 1, Tab 37 [64].

8 Exhibit 1, Tab 37.

9 Exhibit 1, Tab 38 and Tab 49.

10 Exhibit 1, Tab 38.

11 Exhibit 1, Tab 37.

12 Exhibit 1, Tab 37 and Tab 50.

13 Exhibit 1, Tab 38 [113].

14 Exhibit 1, Tab 49.

15 Exhibit 1, Tab 38 [111].

[2023] WACOR 38 and said that he “had a spirit talking to him in each ear and he had to work out which one was evil.”16 Ashley’s father saw Ashley become less rational and more argumentative.17

15. At one stage Ashley told his parents “he had lost his Home, his Car, his Boat, his Family and his Life that he had planned.”18 They believe he tried to keep putting on a brave face, but all the pressure eventually broke him.

16. In early January 2019, Ashley began to exhibit bizarre behaviour. He said he was under spiritual attack. Ashley described feeling claustrophobic and couldn’t stand to be in the house, so he would go outside and lie on the lawn or pavers. He would then go to the opposite extreme and lock himself in the toilet and refuse to come out.

Ashley expressed paranoid thoughts of being tracked and he deleted his social media and email accounts.19

17. Ashley told his mother that he couldn’t cope and wanted to be taken to hospital. On the drive to Fiona Stanley Hospital (FSH), Ashley told his mother she needed to stop the car, so she pulled over on Roe Highway and he got out. She eventually persuaded him to get back in the car and delivered him to FSH, but it seems Ashley left soon after. Ashley rang his sister and asked to be picked up from the hospital. When she collected him, he seemed erratic and asked her to drive him to a number of different places, but she eventually persuaded him to let her take him home.20

18. A few days after, Ashley’s paternal grandfather came to visit. While he was there, Ashley asked if he could borrow his grandfather’s car. When his grandfather declined, Ashley went out into the backyard and screamed and wailed. He had never behaved like that before, so his family were very concerned.21

19. On 6 January 2019, Ashley was behaving strangely, going back and forth to the backyard shed and throwing out his personal items and photographs. He then took a fishing knife from the shed and said he was going to the park. He came back some time later and it was apparent he had cut himself on his arm and leg. He had also taken a quantity of tablets that he had apparently been saving up. Ashley was taken by ambulance to FSH, where he required suturing to his left arm and right knee. He was then placed under the Mental Health Act 2014 (WA) and admitted for psychiatric treatment.22 This was Ashley’s first mental health admission and it was his parents’ first insight “that something was terribly wrong with Ashley.”23

20. Ashley was transferred to the Armadale Health Service inpatient unit for further management as a voluntary patient on 9 January 2019. He remained admitted as a patient, under the care of Consultant Psychiatrist Dr Munib, for 22 days. Ashley’s symptoms included intrusive thoughts that he might injure or kill his parents (which is 16 Exhibit 1, Tab 38 [112].

17 Exhibit 1, Tab 38.

18 Exhibit 1, Tab 49, pp. 2 – 3.

19 Exhibit 1, Tab 38.

20 Exhibit 1, Tab 38 and Tab 46.

21 Exhibit 1, Tab 38.

22 Exhibit 1, Tab 38 and Tab 46 and Tab 47.

23 Exhibit 1, Tab 49, p. 1.

[2023] WACOR 38 why he had tried to harm himself to prevent this happening), thought disorder and functional decline. Ashley was eventually diagnosed with paranoid schizophrenia and depression. He was seen by a second psychiatrist, who confirmed the diagnosis.

Ashley was started on the antidepressant medication escitalopram and antipsychotic medication olanzapine. His mental state improved with treatment and he was eventually discharged and referred to the local community mental health team, the Eudoria Street Centre in Armadale, for management.24

SECOND HOSPITAL ADMISSION – APRIL/MAY 2019

21. Ashley was said to be unhappy with his diagnosis and disagreed with it.25 This appeared to affect his willingness to take his prescribed medication. Ashley saw his GP on 5 February 2019 for ongoing management of his wound to his left arm. They discussed his recent psychiatric admission and Ashley said he felt he had been suffering from an acute anxiety attack rather than having schizophrenia. Ashley spoke of focussing on managing his debts and building a relationship with his daughter.26

22. Ashley was assessed by a social worker as part of the community mental health team on 13 February 2019 and he stated he had not taken any medication since his discharge.27

23. He was seen by a psychiatric registrar on 22 February 2019, Dr Vu, who thought Ashley might be suffering from mixed anxiety and depression. He recommenced Ashley on the antidepressant escitalopram, but initially did not restart him on his antipsychotic.28

24. Ashley saw his GP again three days later they discussed the fact Ashley was feeling much improved and more future focussed. He felt supported by his parents and other relatives and appeared to have good insight. A Mental Health Care Plan was completed.29

25. After Dr Vu saw Ashley again with his mother on 1 March 2019, he also recommenced Ashley on the antipsychotic olanzapine as his impression of the diagnosis reverted to schizophreniform disorder in addition to anxiety and depression.30 It appears Ashley again became non-compliant with his medication after this visit.

26. Ashley was given a clearance for work on 11 March 2019.31 Ashley went back to working for a mining company as a truck driver as a ‘fly in fly out’ (FIFO) worker.32 In late April 2019, Ashley relapsed while off site and at home in Perth. He was living 24 Exhibit 1, Tab 46 and Tab 47.

25 Exhibit 1, Tab 46.

26 Exhibit 1, Tab 43.

27 Exhibit 1, Tab 46.

28 Exhibit 1, Tab 46 and Tab 47.

29 Exhibit 1, Tab 43.

30 Exhibit 1, Tab 46 and Tab 47.

31 Exhibit 1, Tab 43.

32 Exhibit 1, Tab 38.

[2023] WACOR 38 in his parents’ home and they recalled Ashley was starving himself but he described it as ‘fasting.’ Ashley then locked himself in his bedroom and wouldn’t come out. He did not return to work and remained in his room for approximately five days. His parents recalled Ashley made the comment that he “wanted to will himself to death.”33 They enlisted his friend to try to get Ashley to come out, but he refused and barricaded himself in his bedroom. As Ashley hadn’t eaten in days and could not be coaxed to come out, his parents eventually resorted to calling emergency services for help.34

27. Police and ambulance staff attended and police officers eventually had to disassemble Ashley’s bed to get him out. 35 Ashley was admitted as an involuntary patient at FSH on 23 April 2019. He presented with religious delusions, was guarded (suspicious) and had a lack of insight and capacity. He was also found to be chronically malnourished.

Ashley made substantial improvement once he was back on his medication and was eventually made a voluntary patient, but he was put on Paliperidone depot medication (a long acting antipsychotic) to improve his medication compliance and keep him well. At a review with his treating team on 15 May 2019, Ashley presented as engaging and bright and showed good capacity to make decisions about treatment.

Ashley had gained some insight into his mental illness by this time and agreed to engage with treatment, including taking some oral medications and the depot antipsychotic, after he left hospital. Accordingly, Ashley was discharged from hospital the following day, being 16 May 2019, to be managed as a voluntary patient by the community mental health team again.36

COMMUNITY SUPERVISION MAY 2019 ONWARDS

28. Ashley was seen regularly by psychiatric registrars as part of his management in the community. He started to complain of side effects of his medication and feeling overmedicated. As a result, his oral antipsychotic was stopped and his depot dose was reduced. On 2 July 2019, Ashley asked to come off the depot antipsychotic as well. He said he did not believe it had any positive effect. Nevertheless, Ashley did consent to receive his depot on that date, and he was also commenced on a medication to help manage the undesirable side effects, in the hope of keeping him compliant.37

29. Ashley’s father recalls that Ashley seemed good when he came out of hospital and was very positive about getting back to work. His parents were happy that he had made progress in his treatment and they did not observe any relapses in his behaviour.

Ashley became very involved in gardening and getting outdoors and appeared to have a lot of positive energy that he was using in a productive way.38 Ashley’s parents did note that, from their perspective, there didn’t seem to be “a solid action plan”39 in terms of his mental health treatment, other than attending the centre and taking his injections. Ashley’s parents were aware that Ashley had enjoyed speaking to a 33 Exhibit 1, Tab 38 [162].

34 Exhibit 1, Tab 38.

35 Exhibit 1, Tab 47.

36 Exhibit 1, Tab 41 and Tab 47.

37 Exhibit 1, Tab 46 and Tab 47.

38 Exhibit 1, Tab 38.

39 Exhibit 1, Tab 49, p. 1.

[2023] WACOR 38 counsellor while in hospital, and he had expressed an interest in having family counselling sessions with them, but that did not eventuate.40

30. Ashley found a new job fairly quickly on a FIFO basis, but he told his parents he didn’t enjoy being away up north and only did one swing. He then found a local job driving trucks and eventually got into asphalting. Ashley didn’t particularly like asphalting and was concerned that it was a job known to be associated with people using drugs, which he did not want to engage in. However, he knew the job very well and was very good at it, so he continued with the work. Although the job was in theory locally based, it still required Ashley to work away quite a bit. Ashley would generally work away on a shift for three to four weeks then come home for a week. He worked in many different locations, including Kalgoorlie, Port Hedland and Esperance.

31. Ashley sought a second opinion on his treatment in the middle of 2019. A multidisciplinary community review then took place to discuss his care on 18 September 2019. It was noted Ashley wanted to change doctors as he felt he was not being listened to sufficiently.41

32. Ashley saw a GP on 20 September 2019 at his usual GP Clinic and mentioned he was not happy with his psychiatric care and wanted to see a private psychiatrist. He was given two names to make enquiries and he was also given prescriptions for his two oral medications.42

33. An appointment was arranged for Ashley to see another psychiatrist, Consultant Psychiatrist Dr Abish Antony, for a second opinion, as requested. He did not attend the scheduled appointment on 11 November 2019, nor another appointment on 6 December 2019, but he did then attend Eudoria Street Centre for his depot injection on 20 December 2019, which was overdue by that time.43

34. Dr Antony, reviewed Ashley for the first time on this date. Dr Antony noted Ashley did not want to continue his medications, in particular his depot injection, and didn’t want to stay with the psychiatric registrar he had been seeing as the registrar “was quite insistent”44 that Ashley needed to continue taking his medication. That’s why Dr Antony had taken over his care.

35. Dr Antony reviewed Ashley and formed the impression Ashley had psychosis that was in remission, as he wasn’t experiencing any acute symptoms at that point in time.

Ashley indicated his main opposition was to continuing to receive his depot antipsychotic. He referred to an issue with side effects, but couldn’t really say what the side effects were and Dr Antony didn’t see any evidence of them on the day.

Dr Antony noted that Ashley wasn’t on the highest dose at that time, which should have reduced the chance of any side effects.45 40 Exhibit 1, Tab 49.

41 Exhibit 1, Tab 46.

42 Exhibit 1, Tab 43.

43 Exhibit 1, Tab 46 and Tab 47; Exhibit 2, Integrated Progress Notes, 20.12.2019, 15:30 NSG.

44 T 11.

45 T 13.

[2023] WACOR 38

36. Dr Antony recommended that Ashley continue to take his depot medication at the same dosage for the time being. Dr Antony said he explained to Ashley that the first year of treatment for schizophrenia is “significantly risky,”46 so they couldn’t risk a change in his dose or amend his treatment “because of the risk of relapse in the first year.”47 Dr Antony indicated to Ashley that a decision to reduce his medication dose could be revisited after a year.48 Dr Antony explained at the inquest that schizophrenia is treatable but rarely curable and people often require lifelong treatment on medication. If they remain in remission for a significant length of time, the pros and cons of discontinuing medication might be considered, but discontinuing medication entirely is quite uncommon.49

37. Dr Antony recalled that Ashley didn’t protest and agreed to keep receiving the depot medication. Ashley was given his outstanding depot dose that day. Dr Antony recalled Ashley said he could not make it to the clinic for his next depot but agreed to find a nearby GP to administer the dose (although this did not eventuate). This was the last time Ashley was psychiatrically reviewed and the last time he received his depot medication.50

38. At the time Dr Antony saw him, Ashley was a voluntary patient. Ashley indicated that he would continue to keep receiving his medication and attend appointments, so there was nothing to indicate that consideration should be given to making Ashley an involuntary patient and putting him on a CTO. Dr Antony also noted there was no indication at that time that he might be violent towards anyone.51 Dr Antony did give evidence that if Ashley had said that he was not willing to keep taking his medication voluntarily, that would have been an indication to consider a change in his status as he had a severe mental illness and the risk of relapse would be high if he was not on his medications. However, given Ashley was cooperative and demonstrated capacity to make an informed decision about continuing treatment, Dr Antony said it was not appropriate to consider any form of treatment order at that stage.52

39. Dr Antony did not see Ashley again. Dr Antony explained that if a person is stable, he might not expect to see a patient for a few months, so it was not unusual he did not see Ashley again straight away. However, Dr Antony did say he would have expected to 53see Ashley again within three months, which did not occur as Ashley stopped engaging with the service.54

46 T 14.

47 T 14.

48 T 11 – 12; Exhibit 1, Tab 46 and Tab 47; Exhibit 2, Integrated Progress Notes, 20.12.2019, 4:27 PM, Dr Abish Antony.

49 T 16.

50 T 11 – 14; Exhibit 1, Tab 46 and Tab 47.

51 T 14 - 16.

52 T 16.

53 T 18.

54 T 17.

[2023] WACOR 38 DISCHARGE FROM THE SERVICE

40. Ashley was working away a lot of the time, and living with his parents when working in Perth. It appeared he was enjoying his job and had become quite settled in the role.55

41. After the appointment with Dr Antony in December 2019, Ashley was very difficult to engage. Repeated phone calls (at least five) and visits (four) by staff from the community mental health service were either unsuccessful or brief. There were several discussions with Ashley’s parents, who reported they thought he was not receiving his depot medication even though he was telling him he did.56

42. Ashley’s parents were aware that Ashley didn’t like taking his medication as he said he didn’t like the way it made him feel physically, although it made his head feel clearer. He had told his parents he didn’t feel he needed to take the medication, as he could just pray to God instead.57 Ashley’s parents, however, supported him receiving the depot medication, as they could see the benefits of it. They were also concerned he had started to drink to excess again. They passed this information on to the community mental health team. When Ashley was able to be contacted, the reason he gave for his non-compliance was his return to FIFO work.58

43. A Clinical Review Meeting at the Eudoria Street Centre discussed Ashley’s case on 20 January 2020 and noted there were ongoing issues with his compliance with medical appointments and depot medication injections. Ashley usually went about 10 days without having his depot each time, because he said he didn’t feel he needed it and he was working FIFO. His depot had been due again on 17 January 2020 but he was still away with work. The case was discussed with Dr Antony and it was agreed Ashley would be followed up for another medical appointment. The follow up occurred, but as noted above, he never attended another appointment or had another depot injection.59

44. Dr Antony gave evidence he was informed that Ashley wasn’t engaging and he requested the case manager keep assisting with efforts to bring him to the clinic. There were also discussions amongst the clinic staff about ways and means to link Ashley with a GP or some service where he was working who might be able to facilitate him receiving his medication. Dr Antony said there was no information to suggest Ashley was displaying any early warning signs of a relapse, so he left the matter with the case manager, who persistently made efforts to contact Ashley at his request.60

45. On 6 March 2020, Ashley had been non-compliant with his treatment for a number of months, including not taking his depot medication. His parents were contacted by clinic staff and they indicated they were concerned, as they had noted Ashley had been drinking alcohol a lot and had been distracted and pacing up and down a bit. Ashley’s 55 Exhibit 1, Tab 38.

56 Exhibit 1, Tab 47.

57 Exhibit 1, Tab 38.

58 Exhibit 1, Tab 47.

59 Exhibit 2, Clinical Review Meeting 20.1.2020.

60 T 18 – 19; Exhibit 2.

[2023] WACOR 38 parents encouraged him to re-engage with his psychiatric treatment as they had ongoing concerns for him, but there was only so much they could do. His mental health team case manager discussed with them possible relapse symptoms, so they could monitor him for signs of a psychotic relapse.61

46. Around this time, Ashley also lost money after selling the investment home he had owned with Tanya. He owed a debt of between $7,000 and $10,000. His parents lent him some money to help pay the settlement fees and other costs and Ashley then sold his boat to help clear the debt. He had repaid the debt by early March, and Ashley moved out of his parents’ home and moved in with a friend in Seville Grove. This made it harder for his parents to monitor his mental health.62

47. A Clinic staff member discussed Ashley’s case with Dr Antony on 19 March 2020. It was noted his depot dose was now two months overdue. Dr Antony advised Ashley would need to be restarted on a loading dose of his depot medication when he eventually re-engaged.63

48. On 25 March 2020, a final home visit was attempted by the community mental health team staff. Ashley was not at home and it was noted he had moved out of the family home. Ashley’s mother was advised that Ashley would be discharged from the service due to his lack of contact with the team. He was considered to be at low risk at that time. Ashley was discharged from the community mental health team the following day. At that time, Ashley’s only documented dynamic risk factor present was current misuse of drugs/alcohol. A discharge letter was sent by the service to Ashley’s GP.64

49. Dr Antony did not recall being consulted about Ashley’s final discharge from the service, although he agreed this would usually occur and there is a note in the Integrated Progress Notes on 25 March 2020 indicating a social worker had spoken to Dr Antony about the situation and advised it was planned to discharge Ashley and Dr Antony agreed. Dr Antony noted that at the relevant time, case managers and care coordinators had been encouraged to look at reducing their caseloads due to the COVID-19 pandemic creating restrictions on their ability to provide care. It was suggested that people who were not engaging, or did not require care, should be discharged. Ashley fell into that category.65

50. Dr Antony explained at the inquest that it was not an option at that stage to simply put Ashley under the Mental Health Act and make him an involuntary patient to force him to engage, as he needed to be seen face-to-face for that to occur. The information coming back from Ashley’s parents was also that he was still saying he was willing to receive the depot, although he was not attending the clinic. Dr Antony said that if the patient was considered risky, then some more attempts might be made to engage him, but beyond a certain point, when someone is a voluntary patient there are limits to 61 Exhibit 1, Tab 47 and Tab 48.

62 Exhibit 1, Tab 37 and Tab 38.

63 Exhibit 2, Integrated Progress Notes, 19.3.2020, 12.00, S Griffiths, SW.

64 Exhibit 1, Tab 46 and Tab 47.

65 T 21; Exhibit 2, Integrated Progress Notes, 25.3.2020, 12.00, S Griffiths, SW..

[2023] WACOR 38 what the clinic staff can do. Therefore, unless Ashley brought himself to the clinic or someone was able to coax him to attend, he couldn’t be forced to do so.66

51. In terms of any drugs or alcohol use, Ashley was not generally known to use illicit drugs. His primary substance use leading up to his death was alcohol, as noted above.

His parents had noticed that he could easily finish off half a carton of beer in one sitting and they had expressed their concern, so he became more covert in his drinking.

They were unaware of whether he drank when working away, as their only knowledge came from what they saw at home. Dr Antony noted that while Ashley was at work, there would likely have been some limits on substance use as part of the job testing requirements, but at home he would have less restriction. After Ashley moved out from his parents’ home in March 2020, there was also less opportunity to observe him when he was in Perth.67

52. Ashley’s parents met up with him at their home on Easter Saturday, 11 April 2020, when he came over to borrow some gardening tools. At that time he seemed well and happy. He had sold his house, which had been a burden for him, and had paid off all of his debts, so he was now able to move on with his life. Ashley seemed positive about the future and in a good place. He was planning to do some gardening with his daughter and they both seemed happy and excited at the prospect. At that time, Ashley’s parents had no reason to suspect there was anything wrong with him and he showed no signs of a psychotic relapse, although his father later told police he had noticed Ashley seemed a little vague.68

53. Ashley’s parents emphasised that Ashley had never been nasty or violent at home.

When he became unwell, he was withdrawn and reclusive and was not confrontational, although he could be argumentative. When relapsing, he would isolate himself in his room and lay under the bed, refusing to come out. Ashley’s parents believed he was generally comfortable with them, but he had isolated from his sister due to his religious beliefs and they did not know a lot of his friends. They had not been around to his new house, although they knew Ashley was borrowing gardening tools so he could work on the garden at his new home. Ashley’s parents were trying to give him some space to settle in to his new house and routine before they went over to see him at his new place.69

54. Ashley made plans to come down to Perth to celebrate Mother’s Day with his parents in May 2020. They were not expecting to see him before then and did not generally communicate with him when he was away at work, so they did not become aware that he had relapsed until it was too late.70

55. Ashley had recently come to an arrangement with Tanya to pay her $300 a month child support as he was working. The last time he saw Tanya was on 16 April 2020, when he dropped Selena home. Tanya did not recall noticing anything different about Ashley at that time, but she had limited knowledge of his health struggles. She was

66 T 19 – 20.

67 T 17 – 18; Exhibit 1, Tab 38.

68 Exhibit 1, Tab 38.

69 Exhibit 1, Tab 38.

70 Exhibit 1, Tab 38.

[2023] WACOR 38 only aware that he had been cancelling visits due to his health. The last time Tanya had contact with Ashley was on the weekend of 24 to 25 April 2020. Ashley had texted to say he would collect Selena on the Saturday, but then texted Tanya on the Saturday morning to say he was unwell from something he ate and couldn’t have Selena after all. Ashley sent another text message a couple of days later to say he would be away for a few weeks, which Tanya assumed was work-related.71

56. Ashley’s housemate, Michael Sopp, had known Ashley for about 15 or 16 years after they met through friends. Ashley and Michael had remained good friends over the years and they had lived together in the past when Ashley was still dating Tanya.

Michael had attended Ashley and Tanya’s wedding, but then didn’t see Ashley for many years. Ashley got back in contact with him when he separated from Tanya and moved back home to Perth to live with his parents. Michael’s contact with Ashley was then intermittent for a time, before they renewed more regular contact in about February 2019. Michael was aware that the divorce had been difficult for Ashley to process. Ashley also explained he had been unwell and spent time in hospital for treatment for schizophrenia and depression. Michael knew Ashley was taking medication and he observed Ashley appearing to be very sedated by the medication, walking and talking slowly and often losing his train of thought. They had discussed that Ashley didn’t like the effect of the medication and that Ashley also had a lot of issues with insomnia.72 However, in terms of his general behaviour, to Michael “he was just normal Ash.”73

57. Michael had observed that Ashley had seemed less affected by his medications when he changed from oral medication to regular injections. However, he was aware Ashley was quite averse to being on any medication and had been talking to his doctors.

Ashley moved in with Michael around the end of February 2019. Ashley had appeared more his normal self, and less affected by medication, at this time and it came up in conversation that he had stopped taking his medication. Michael understood from Ashley that he had stopped taking the medication as he was doing well and, in effect, didn’t need it anymore. Michael did notice that Ashley appeared to be back to his usual self, so he was reassured that Ashley was improving and had no concerns about his behaviour at that stage. Ashley appeared his usual calm self and never exhibited any behaviour that could be described as aggressive or violent.74 Michael described Ashley as “a good mate and a good bloke”75 and nothing changed at any stage to make him think Ashley might change from the laid back friend he knew.

58. Michael recalled Ashley generally stayed by himself in his room at their shared house unless his daughter Selena was staying with him. Ashley generally seemed okay and was very happy when Selena was visiting. Michael and Ashley were renovating the back garden in their downtime as they couldn’t go out much due to COVID-19 restrictions, and Ashley enjoyed the gardening work. Michael was aware Ashley was 71 Exhibit 1, Tab 37.1 and Tab 37.3 and Tab 50.

72 T 49; Exhibit 1, Tab 39.

73 T 47.

74 T 47 - 50; Exhibit 1, Tab 39.

75 T 50.

[2023] WACOR 38 Christian and they discussed his religion a little bit, but Michael is an atheist and Ashley did not try to impose his beliefs upon him.76

DETERIORATION IN ASHLEY’S MENTAL STATE

59. Dr Antony indicated that a relapse can occur very quickly in some people, and that appears to have been the case for Ashley based on his past history, and the events in April 2020.77

60. It seems that most of Ashley’s colleagues were aware that he was going through some personal issues, was very depressed about the breakdown of his marriage and was taking medication for his depression that affected the way he acted and responded to things. He had disclosed this information to his employer during his job interview and shared it with colleagues. However, none of Ashley’s work colleagues, including his employer, were aware of the full extent of his mental illness and the fact that he had experienced psychosis and was not taking his anti-psychotic medication. Dr Antony confirmed it was Ashley’s private information and could only be passed on to his employer with Ashley’s permission, which was never discussed with Dr Antony. His parents had been included to some extent in Ashley’s care with his consent, so they had been advised of signs of relapse to monitor, but they were obviously not with him in those final days and it was not their role to pass on Ashley’s private information either.78

61. As it was, it became clear to Ashley’s work colleagues that Ashley was experiencing a deterioration in his mental health, but they were not in a position to appreciate the full extent of it. They knew him as quiet and reserved and he had not formed close friendships with any of them, so it was hard for them to know how troubled he was until it was too late. Ashley had left work unexpectedly and flown home just before Easter 2020 as he told his employer that his ex-wife had fallen ill and he needed to go home and care for his daughter. Ashley was immediately put on a plane and returned to Perth. Ashley remained in Perth and did not return to work until after the Easter break.79

62. Up until the last week before his death, Ashley had seemed happy and his normal self.

Ashley’s housemate, Michael Sopp, recalled that when Ashley came back from his last swing he looked “tired and wiped out”80 and said he wasn’t sleeping much. They discussed his medication and Michael suggested he should talk to his doctor and find ways of coping with the dangers and side effects of his psychiatric drugs. However, Ashley wasn’t keen and simply said he didn’t want to take the prescription drugs anymore. Michael was aware Ashley smoked cannabis occasionally and he would drink beer every day, but rarely to excess, and he didn’t seem to be keen on using substances to manage his mood.81 76 T 47 - 49; Exhibit 1, Tab 39.

77 T 25.

78 T 25; Exhibit 1, Tab 11 and Tab 14.

79 T 38; Exhibit 1, Tab 14.

80 Exhibit 1, Tab 39 [52].

81 Exhibit 1, Tab 39.

[2023] WACOR 38

63. In that last week, Ashley told Michael he was sometimes getting only an hour of sleep a night. This was having an effect on him and Michael recalled Ashley looked tired and exhausted on the weekend before he returned to work. Ashley also seemed like he had a lot on his mind. Michael said he tried talking to Ashley, and Ashley did open up a little bit, but he described the same issues he had been struggling with for some time.

Michael thought Ashley was just preoccupied, which was making him more quiet and withdrawn than usual.82

64. Michael gave evidence that he had felt at the end that Ashley didn’t want to go back to work for his next shift as he was going to be away for a long time and didn’t want to be away from Selena. They had talked about Ashley trying to get a job based in Perth, but Michael recalled Ashley seemed to have come to accept that he would have to travel to make a living. Accordingly, Ashley left for work early on the Tuesday morning, as scheduled. Michael did not talk to Ashley again.83

65. At the inquest, Michael said that he had thought about asking Ashley whether he was “in his right mind to go back to work because he seemed quite down.”84 In hindsight, Michael wished he had tried to talk to Ashley about it, but he remembered that Ashley could be quite stubborn once he made up his mind about something, and it seemed at the time that Ashley had made up his mind that he was going to do the shift. Michael had also not seen any signs or symptoms to suggest that Ashley was delusional or relapsing in psychosis. He was just concerned that Ashley seemed depressed before he left.85

66. Ashley was working for his employer on a Main Roads WA road maintenance project close to South Hedland in April 2020. He flew back to Port Hedland with some work colleagues on Tuesday, 28 April 2020, to start another shift. Ashley and his colleagues were staying at The Lodge Motel in Hawke Place, South Hedland. Ashley was staying in Room 57, next door to another worker, Jimmy Wood. Mr Wood had known Ashley for a couple of years as they had previously worked together at a different company.

Mr Wood recalled Ashley in the past as being friendly and talkative, but when Ashley started working at AAA Asphalt he noticed Ashley was different. Mr Wood said Ashley seemed more distant and slower to react in situations and not as ‘chirpy’ as before. Mr Wood did not talk to Ashley about his personal life but he was aware from some of the other boys on site that Ashley had depression and was struggling.86

67. A member of Ashley’s work crew, Reece McSweeney, noticed that Ashley started acting differently around Wednesday, 29 April 2020. He lost his phone on site that day and his behaviour then shifted. Mr McSweeney recalled that Ashley “was always kind of spaced out but when he lost his phone he got a lot worse.”87 Mr McSweeney thought perhaps Ashley used the phone to distract himself from his internal thoughts, and without the phone he had nothing to distract him. That day some equipment broke down, so they knocked off early at about 1.00 pm and returned to their

82 T 48.

83 T 51; Exhibit 1, Tab 39.

84 T 51.

85 T 52.

86 Exhibit 1, Tab 10.

87 Exhibit 1, Tab 11 [10].

[2023] WACOR 38 accommodation at The Lodge. Ashley was required to do drug screening for his work every 28 days, so he went and got tested that afternoon. No common illicit drugs were detected.88 Ashley was, however, seen drinking beer while at the Lodge.89 His supervisor, Michael North, had visited Ashley’s room that day to get some forms signed and had noticed he had three boxes of Panadol and a carton of Budweiser beer on the table. Mr North asked Ashley if he was okay or needed to talk, but Ashley said he was “all good and hadn’t been sleeping.”90

68. On Thursday, 30 April 2020, some of the AAA Asphalt workers, including Ashley, were given the day off work because the plant was still broken down. Ashley was seen pacing around the accommodation for most of the day or else lying on his bed in his room, staring at the ceiling. Mr Wood was watching a movie in his room in the afternoon and saw Ashley pacing outside, doing circles around the accommodation block. Ashley had a beer in his hand and was drinking as he walked. Mr Wood did not see Ashley at dinner or before he went to bed at about 10.30 pm. Mr Wood was woken at about 2.00 am on 1 May 2020 by the sound of Ashley’s door shutting. He got up and looked outside and saw Ashley walking across the road. Mr Wood called out to Ashley and asked what he was doing and whether he had been to bed yet. Ashley said he hadn’t and Mr Wood then asked whether he would go to work if he hadn’t slept.

Ashley said “No,” so Mr Wood suggested he would need to try and get a phone to call someone if he wasn’t going to make it to work, as he was aware Ashley had lost his phone the day before. Mr Wood then said, “Do you want a smoke? Do you want to talk?” Ashley said “No” and walked off, so Mr Wood returned to bed.91

69. Sometime after, Mr Wood heard a knock at the door and opened it to find Ashley there. Ashley asked if he could use Mr Wood’s phone, so Mr Wood unlocked it and gave it to him. Ashley walked to his room with the phone while Mr Wood waited outside and smoked a cigarette. After having a smoke, Mr Wood went to Ashley’s room and spoke to Ashley, who asked if he could keep the phone for an hour.

Mr Wood returned to his own room briefly, but then went back to Ashley’s room and asked for his phone back as he didn’t know Ashley that well. After he returned to his room with his phone, Mr Wood checked his phone and noted it didn’t appear Mr Wood had called anyone. In the search history, it appeared Ashley had googled ‘synonym for container,’ which didn’t make any sense to him. He later took a photo of the message and sent it to his wife to see if she could understand what it might mean.

Mr Wood went back to bed, but could hear Ashley still continuously walking up and down outside.92

70. Mr Wood got out of bed at 5.40 am and decided he had better go and check on Ashley, given his behaviour overnight. He went to Ashley’s room and pushed open the unlocked door. He could see the clothes Ashley had been wearing the night before were laid out on the bed. The bathroom door was shut and the light was on, so Mr Wood called out to Ashley through the bathroom door. When Ashley didn’t 88 Exhibit 1, Tab 40.

89 Exhibit 1, Tab 11.

90 Exhibit 1, Tab 13 [17].

91 Exhibit 1, Tab 10.

92 Exhibit 1, Tab 10.

[2023] WACOR 38 respond, Mr Wood called his supervisor, Michael North, and explained his concerns for Ashley.93

71. Mr North had been working with Ashley since Ashley had started at the company. He knew Ashley as quiet, but always happy and jovial. He hadn’t seen Ashley the night before, so this was the first time he had become aware that there was something wrong with Ashley, although he did say in his statement that he had been a little worried about Ashley after visiting him in his room a couple of days before.94 After being contacted by Mr Wood, Mr North came to Ashley’s room at about 5.45 am. The door was unlocked and he entered the room and checked the bathroom, but Ashley was not in there.95 Mr North noticed some Panadol scattered on the table near the doorway and a couple of Budweiser stubbies but nothing that seemed particularly alarming.

Mr Wood said he directed Mr North to some notes Ashley had written96 and said to Mr North, “He’s lost the plot. I think he’s committed suicide, have a look at the letter.”97 Mr North said he looked at the note and it seemed to him to be ramblings. He did think it was quite unusual but it didn’t raise any specific alarm bells at that time.98

72. Mr North and Mr Wood couldn’t try calling Ashley, as they knew he had lost his phone. However, they were then informed by another worker that Ashley was over near the crew truck. Mr Wood walked over and saw Ashley sitting in a crew truck, dressed and apparently ready to go to work. There was evidence he had been to the restaurant and eaten breakfast in an ordinary manner. His colleagues noticed that he seemed even more subdued than normal, but as he appeared ready to go to work, Mr North said he decided they would deal with it onsite, so they headed off to site.99

73. When they arrived at the site, Ashley seemed ‘spaced out.’ Reece McSweeney said he could see Ashley was having a bad day and offered him a hug, which he accepted.

They had a pre-start meeting and underwent temperature testing as part of COVID-19 testing. After the meeting, most of the workers headed off to their allocated tasks, but Mr North asked Ashley to remain with him. Mr North then raised with Frank Italiano, the owner of the business, his concerns about Ashley’s mental state.100

74. Mr Italiano said he felt he knew Ashley fairly well. He had flown up next to Ashley on the plane two days earlier and had thought Ashley looked pretty well and seemed pretty happy at that stage. There had been a couple of issues in the preceding days and Mr Italiano said he had been aware there were “some grumblings”101 about Ashley’s work performance, but he was also aware that Ashley had been through some hard times and he had had felt it was better for Ashley to keep working and keep occupied in meaningful employment while working through his personal issues.102 93 Exhibit 1, Tab 10.

94 T 54; Exhibit 1, Tab 13.

95 Exhibit 1, Tab 10.

96 Exhibit 1, Tab 36.

97 Exhibit 1, Tab 10 [76].

98 T 55.

99 T 54; Exhibit 1, Tab 10 and Tab 16.

100 T 56.

101 T 37.

102 T 32, 38 .

[2023] WACOR 38

75. On this morning, Mr North told Mr Italiano that he was concerned as he had received feedback from some of the other workers that Ashley hadn’t slept well and wasn’t looking too well. They could see Ashley’s demeanour was different to usual and they were concerned for him, but thought it might simply be that he was not sleeping well due to his relationship breakdown and other personal matters. At that stage, Mr Italiano and Mr North agreed they would need to keep an eye on Ashley and monitor him to make sure he was alright. They also agreed that Ashley should be told he couldn’t operate any of the machinery that day, as they were concerned if he was distracted and thinking about something else, which seemed evident, it might lead to an accident and Ashley could hurt himself or someone else. Mr North told Ashley that he was concerned for him and thought he might need to go home. Ashley agreed and said he wanted to go home. Mr North asked him if he was happy to remain onsite until they could get him a flight home. Ashley said he was, so Mr North told Ashley he couldn’t operate any machinery but he could remain with his co-workers on site until the afternoon, when he would hopefully fly home. Mr North gave evidence that Ashley was normally a great worker who was good at his job and never gave attitude, so he wasn’t expecting what happened next.103

76. For the next hour or so, Ashley was seen by his co-workers pacing around the site.

Some of them told him to move to the side so he wasn’t in the way. Mr McSweeney was working close to the live lane, that was open to passing traffic, and he noticed Ashley kept walking over towards him and the incoming traffic. Mr McSweeney was worried Ashley might be trying to throw himself in front of traffic, so he asked him to get in the bobcat and sweep up for him, in order to keep him busy, not knowing that Ashley had been told he couldn’t operate machinery that day. Mr North had been working laying asphalt, but when he realised Ashley was operating machinery, he stopped and approached Ashley and told him to get out of the bobcat again.

Mr McSweeney stated he spoke to Mr North and expressed his concern for Ashley’s safety at that time. He felt they needed to get Ashley off site as he might harm himself, and suggested they move him back to the plant area, away from where the asphalt was being prepared, but where he could be supervised. Mr North said he would sort it out.104

77. Mr North went back to laying asphalt, but then noticed that Ashley was operating machinery again. Mr North stopped and spoke to Ashley three times before telling Ashley that he would need to stay with him from then on, as he had a duty of care to ensure no one got hurt. Mr North recalled that from that point, something changed.

Ashley started pacing up and down the road, coming up fast behind Mr North before storming off again. Mr North was concerned, so he rang Mr Italiano and asked him to come back.105

78. Mr McSweeney had kept working and he recalled he was approached by Ashley again at about 9.00 am. Mr McSweeney asked Ashley if he was okay and offered him a cigarette. Ashley replied in a softly spoken monotone voice, “I feel like killing people.”106 Mr McSweeney said he responded by encouraging Ashley to find ways to

103 T 34 – 35, 38, 56 - 58.

104 T 56 – 57; Exhibit 1, Tab 11.

105 T 57.

106 Exhibit 1, Tab 11 [55].

[2023] WACOR 38 manage the hate he was feeling inside himself and find a healthy way to release it. He then gave Ashley a hug and sent a text to Ashley’s phone, so that when he found it he would have his number and be able to contact him if he needed. Mr McSweeney recalled Ashley looked at him blankly for a while then thanked him and left.107

79. By this time, Mr North had organised a flight home for Ashley through Mr Italiano’s wife. He told Ashley that the flight had been arranged and around this time, Mr Italiano returned to the site in his Toyota Prado. He was informed Ashley had been trying to operate machinery and then Ashley barged past Mr Italiano and got into the driver’s seat of the Prado and tried to start the car. Mr Italiano had the car keys in his pocket, so the car would not start. When Ashley tried to close the driver’s side door, Mr Italiano grabbed it and held it open. He said to Ashley, “What are you doing mate?” and Ashley responded, “I’ve gotta go, I just gotta go.”108 Mr Italiano said it was clear Ashley wasn’t happy there, so he told Ashley he would take him back to their accommodation. Ashley got into the passenger seat of the car and sat quietly while Mr Italiano got into the driver’s seat and began to drive Ashley back to The Lodge.109 Mr Italiano said in evidence that Ashley didn’t appear erratic at that stage, but rather seemed “almost shut down.”110

80. The car trip took approximately 30 minutes. During the car trip, Mr Italiano tried to engage Ashley but Ashley did not say a word in reply. Mr Italiano kept talking to Ashley about his health and told him he was happy to send him home so he could feel better, and that they were arranging a flight for him. Ashley did not appear to react to his words. Mr Italiano also asked Ashley whether he wanted to go to hospital, but he didn’t respond. Mr Italiano could see Ashley clenching and unclenching fists and leaning forward. It occurred to Mr Italiano that Ashley might ‘have a go’ at him, but nothing happened during the drive and Ashley never spoke a word to Mr Italiano during the drive.111

81. Just as they were pulling up at The Lodge and while the car was still moving, Ashley opened the passenger door and almost fell out of the vehicle. Mr Italiano quickly stopped the car and Ashley got out of the car immediately. He then turned towards Mr Italiano and lunged at him through the open car door, trying to punch Mr Italiano in the face. Mr Italiano said the blow was not forceful and he easily deflected Ashley’s fist. Mr Italiano then said, “Mate, what are you doing? We’re just trying to help you.

Please go to your room, have a drink of water and relax.” Ashley slammed the door hard and then appeared to run off towards his room. Mr Italiano drove off slowly through the motel carpark. He said he was a little shocked at that stage and pondering whether he should have taken Ashley to hospital but it didn’t occur to him at that time to call the police. Ashley had seemed half-hearted in his attempt to strike Mr Italiano and he thought Ashley was just going to go to his room and wait until it was time to fly home. Mr Italiano began driving back towards the worksite and had only been gone a few minutes when he received a phone call from the manager at The Lodge.

107 Exhibit 1, Tab 11.

108 Exhibit 2, Tab 14 [77] – [78].

109 T 35; Exhibit 1, Tab 11 and Tab 13.

110 T 36.

111 T 36; Exhibit 1, Tab 14.

[2023] WACOR 38 The manager told him that Ashley had grabbed a knife and was trying to kill people.

Mr Italiano immediately turned his car around and headed back to the motel.112

EVENTS AT THE MOTEL

82. Xiaoyan (Yan) Xi was working as the receptionist at the motel that morning. She saw Ashley walk in through the reception area’s front door at about 10.00 am. She knew Ashley as a resident at the motel and said ‘Good Morning’ to him, but then observed he “had an evil look on his face.”113 Ashley walked directly past her into the restaurant and then towards the kitchen. Ms Xi followed him and watched him walk into the kitchen and take a large chef’s knife off the wall. Ashley walked back out of the kitchen towards Ms Xi and then raised the knife in his left hand and grabbed her shoulder with his right hand. Ms Xi said, “Ashley, what is wrong?” and he replied, “I’ll kill you. I’ll kill everyone.”114 He brought the knife down towards her left shoulder and stopped with the knife tip just above her shoulder, then paused. Ms Xi took the opportunity to break free of his grip and she began to run. Ashley chased her around the restaurant. His eyes appeared blank and he wasn’t saying anything as he ran after her. Ashley threw the knife towards Ms Xi, and it just missed her. She froze and watched as Ashley ran back into the kitchen and took another large chef’s knife off the wall.115

83. Hedja (Heather) Handzic was working as a breakfast chef at the motel and she was cleaning the grill when Ashley had walked in and picked up the knife. She saw him return to the kitchen and then come at her with the knife raised in his hand while grabbing her left shoulder with his hand very hard. Ashley did not say anything and his eyes looked very red. Ms Handzic fell backwards and screamed. Ms Xi also called out and ran towards Ashley. She grabbed at his shirt, pulling him back towards her and away from Ms Handzic, allowing Ms Handzic to get free. Ashley then turned and chased Ms Xi out of the kitchen, while Ms Xi yelled at Ms Handzic to run away.

Ms Xi grabbed a trolley in the restaurant and pushed it between herself and Ashley and then pushed the trolley towards him to block his access to her. Ashley made slashing motions towards Ms Xi with the knife before turning and walked back through the front door. Ms Xi watched him head to the road and cross Hawke Place towards the South Hedland Courthouse. Ms Xi saw people outside the Courthouse and yelled to them to go inside. Ashley stopped in the middle of the road and looked back at Ms Xi. His face looked angry and red and he started walking back towards her again with the knife still in his hand, so Ms Xi ran back into the reception area and locked the door. She tried to call the police but couldn’t get through, so she rang the afternoon chef, Made Suwito, and asked him to come and help. She then called the police again, but still couldn’t get through, so she called Mr Italiano. Ms Xi then tried to alert other staff and guests at the motel to the danger and advised them to remain in their rooms.116 112 T 39 – 40, 42 – 43, 44; Exhibit 1, Tab 14.

113 Exhibit 1, Tab 15 [11].

114 Exhibit 1, Tab 15 [26] – [27].

115 Exhibit 1, Tab 15.

116 Exhibit 1, Tab 15 and Tab 16.

[2023] WACOR 38

84. Mr Suwito left his room and walked towards the reception area. He came across Ashley in the carpark. Ashley turned and looked at him and Mr Suwito then noticed him raise his hands above his head. Mr Suwito recognised his chef’s knife in Ashley’s hand and knew it was sharp as he had sharpened it the week before. Mr Suwito then turned and ran. Ashley chased him and Mr Suwito feared for his life. Mr Suwito passed a housekeeper as he ran and he called out to her to go into a room and lock the door. Mr Suwito kept running and made his way up the stairs and to the manager’s room. Ms Handzic had run out the restaurant door towards the swimming pool and she also ran to the manager’s room, where she met up with Mr Suwito. They both went into the manager’s apartment and locked the door before calling the police.117 The motel staff were all very frightened and one of them required medical treatment after twisting his ankle running away, but none of them were injured by Ashley.

85. A guest at The Lodge, Telisha Samson, had just checked in and was standing outside her room having a cigarette when she was approached by Ashley who was holding the knife in his right hand. When she made eye contact with Ashley, he raised the knife to shoulder height as if intending to stab her. Ms Samson thought he intended to kill her, so she immediately jumped forward and started to run, but in her panic she slipped and fell over.118

86. Ms Samson turned and saw Ashley walking slowly towards her with the knife still raised up in front of him. Ms Samson felt panicked and tried to get up. She had got to her knees when Ashley reached her and slashed out with the knife towards her.

Ms Samson raised both arms in front of her face for protection, turned her head and screamed as loud as she could. Ashley missed her with the knife, so Ms Samson opened her eyes and grabbed his forearm to try to pull his arm down. Ashley pulled his arm out of her grip and stabbed at Ms Samson again, this time making contact and stabbing her in the back of her left arm. Ms Samson called out and tried kicking out at Ashley’s legs but didn’t manage to make contact. Ashley lashed out again with the knife and struck Ms Samson on her left arm near the shoulder. She screamed out in pain and Ashley then pulled out the knife and turned and ran away across the carpark.

Ms Samson made her way back to her room, where her friend was already on the phone to emergency services requesting an ambulance attend. Ms Samson had two cuts on her arm and her friends gave her first aid until an ambulance arrived and took her to hospital where she received stitches to her arm. Ms Samson later told police she had never met Ashley and had no idea why he did what he did. She stated she felt “lucky not to have been more seriously hurt or even killed.”119

87. Ms Samson’s sister had been in the hotel room and witnessed the attack. She called police at 9.52 am, which appears to be the first time the police became aware of the unfolding events. Many more calls came in from members of the public after that time as Ashley made his way through the street in South Hedland to the nearby shopping centre. It’s clear from the records that all of these events took place very quickly, with the call for an ambulance after Ashley was shot received by St John Ambulance at 9.57 am.120 117 Exhibit 1, Tab 16 and Tab 17.

118 Exhibit 1, Tab 18.

119 Exhibit 1, Tab 18 [40].

120 Exhibit 1, Tab 33.

[2023] WACOR 38

88. When Mr Italiano arrived back at the motel, Ashley had already run away. Two of the motel staff came out of the locked reception area and told him what had happened. A police van then pulled up and Mr Italiano heard over the police radio that Ashley was at the shopping centre. Not long after, Mr Italiano was informed that Ashley had been shot, so he returned to the worksite to inform the other staff and they finished up work early.121

EVENTS IN THE STREET

89. After stabbing Ms Samson, Ashley ran up to Throssell Road. At about 9.52 am, Austin Bung was walking towards the McDonald’s restaurant on Throssell Road when he heard someone running behind him. He turned and saw Ashley running at him with a big knife. Mr Bung turned and tried to run away but tripped. As he tripped, he felt Ashley stab him. Mr Bung fell over onto his back. Ashley was still trying to swing the knife towards him, so Mr Bung tried to push himself out of the way. Ashley stopped suddenly and then started to run towards McDonald’s, leaving Mr Bung on the ground. Fortunately, Mr Bung had only a minor injury and did not require medical assistance.122

90. Kingsley Jones was walking to the South Hedland Courthouse and decided to stop at McDonald’s on the way. He had just purchased some drinks and was walking back into the McDonald’s carpark on Throssell Road when he saw Ashley walking fast towards him. Mr Jones had never met Ashley, but Ashley appeared focussed on him.

Mr Jones began to walk in a different direction and noticed Ashley changed his direction to match, so that they were on a collision course. When he was about two metres away, Mr Jones saw Ashley was holding a knife. Mr Jones said, “What are you doing?”123 Ashley responded by moving closer and lifting his right hand up over his head and bringing the knife down very quickly. He stabbed Mr Jones with the knife in his left shoulder blade, very close to the back of his neck. Mr Jones felt a stabbing pain as the blade entered his body. Ashley then pulled the knife out and stabbed Mr Jones again in the same place. As he pulled the knife out the second time, Mr Jones ran to his left to get away. He saw Ashley appear to try to follow him but Mr Jones was too fast and managed to run across the road. Ashley then seemed to lose interest in him and Mr Jones saw Ashley run off towards the McDonald’s store. A passing motorist stopped and took Mr Jones to the hospital, where he received emergency treatment, including sutures to the wound in his shoulder.124

91. Connor Herwig had stopped at the McDonald’s carpark to get breakfast. He parked his car in the carpark and walked into the restaurant. After placing and collecting his order, Mr Herwig walked back to his car. After opening the driver’s side door and sitting on the driver’s seat, he saw Ashley rushing towards the car parked next to him.

Mr Herwig noticed Ashley had no facial expression and appeared “almost as if he was scared in a way,” although he did not say anything. Mr Herwig heard a sound, like a 121 Exhibit 1, Tab 14.

122 Exhibit 1, Tab 19.

123 Exhibit 1, Tab 20 [18].

124 Exhibit 1, Tab 20.

[2023] WACOR 38 body part striking the other car, then he saw Ashley coming around towards his open car door. Ashley reached in through the open door with his left hand in a sharp and fast motion. Mr Herwig said words to the effect, “What are you doing?”125 and pushed back at him. He then saw Ashley raise a large knife above his neck. That’s when Mr Herwig realised he had been stabbed in the neck, on the right side towards the front. Mr Herwig could see the determination on Ashley’s face as he continued to stab towards him with the knife. Mr Herwig turned onto his back and kicked out at Ashley through the open door in order to defend himself. Ashley kept stabbing towards him and sliced the top of Mr Herwig’s right ankle with the knife. It then appeared to Mr Herwig that Ashley seemed to give up on him and turn his attention in the direction of the McDonald’s restaurant, walking in that direction.126

92. Mr Herwig saw Ashley approach a couple who were in front of the McDonald’s, pushing a trolley. Mr Herwig shouted out to get Ashley’s attention away from the couple and also because he was angry at being stabbed. Ashley turned back and started running towards him, so Mr Herwig threw his coffee at him and ran around the front of his car. Ashley appeared to follow him for a second, before “he just instantly turned and ran straight towards the shops.”127 Mr Herwig saw Ashley run straight to the McDonald’s side/Kmart side entry of the centre and then heard a woman screaming. A bystander took Mr Herwig to hospital, where he received stitches to a cut on his clavicle bone and to his right ankle.128

THE SHOOTING AT THE SHOPPING CENTRE

93. The South Hedland Square shopping centre (the shopping centre) has an interior mall arranged in a cross shape around a central open hub area. The final events involving Ashley occurred in the eastern mall, near the central hub area, but he first entered near the Kmart store, which is down a passageway from the central hub area.129

94. Konrad Frost had finished his night shift as a truck driver and was walking out of the main entrance of the shopping centre, near Kmart. He noticed two police officers talking to a Kmart staff member as he was leaving. As he exited the centre, Mr Frost saw Ashley coming towards him. He turned to face him in order to see why Ashley, who he did not know, was getting so close to him. As Ashley got within arm’s reach, he lunged at Mr Frost with his right hand and Mr Frost felt a thud in his neck. Mr Frost stepped back and Ashley stood facing him for a second “with crazy eyes not saying anything then turned and ran away.”130 Mr Frost saw at that time that Ashley was holding a knife. Mr Frost tried to call ‘000’ but then started to feel unwell and looked down, at which time he noticed there was blood on his shirt and he realised he had been stabbed.131 125 Exhibit 1, Tab 21 [14].

126 Exhibit 1, Tab 21.

127 Exhibit 1, Tab 21 [25[.

128 Exhibit 1, Tab 22.

129 Exhibit 1, Tab 45.

130 Exhibit 1, Tab 22 [17].

131 Exhibit 1, Tab 22.

[2023] WACOR 38

95. Mr Frost ran back into the foyer of the shopping centre after Ashley and saw Ashley approaching a woman with a baby. He called out to Ashley to try to distract him, but was too far away to stop Ashley as he stabbed the woman. Ashley then turned and ran back towards Mr Frost. He swung towards Mr Frost with the knife, but Mr Frost stepped back and Ashley missed. Ashley then turned and ran further into the shopping centre. Mr Frost tried to follow him and call out to other shoppers to warn them, but began to feel weak due to blood loss and had to sit down. Mr Frost was taken by ambulance to the local hospital and then transferred by Royal Flying Doctor Service to Royal Perth Hospital for specialist trauma treatment due to the severity of his injuries.

He recovered after treatment.132

96. Kimberley Abbott was the mother with the young baby. She had put her one year old daughter in a trolley covered with a padded trolley cover. They went shopping together in Kmart and then visited a chemist. As she approached the chemist she saw two police officers talking to the Kmart manager at the front of the store. Ms Abbott had finished her errands and was moving to the exit closest to McDonald’s. She walked out through the automated doors and into the foyer area. She came across Ashley who appeared to be stumbling/rushing through the left door opposite her.

Ashley was looking back behind him like someone was following him. Ms Abbott was about two metres away from Ashley and walking through the right door when Ashley approached Ms Abbott and stabbed her to the back below the neck in her left shoulder blade area. She had not seen the knife beforehand, but once she was stabbed she looked at him and saw the knife in his hand. As Ashley pulled the knife back it appeared to Ms Abbott that Ashley was smiling. Ms Abbott yelled at him but Ashley did not respond. Ms Abbott then called out for help and saw the two police officers near the Kmart entrance notice her. Ashley then started to run into the shopping centre and she saw the police officers chase after him. Ms Abbott’s instinct was to try to protect her daughter, so she pushed the trolley into the corner of the foyer and called out, saying “Help I’ve been stabbed, someone get my baby.”133 She was bleeding heavily and collapsed to her knees. People came to help and looked after Ms Abbott’s daughter and provided first aid, before a police officer came to assist and support Ms Abbott until an ambulance was available. Ms Abbott was eventually taken by ambulance to hospital, where she received sutures to a wound on her back.134

97. Esther Brooks was shopping at the centre with her partner and was walking towards the Kmart exit when she heard a woman screaming for help and saw Ashley running towards her with two police officers running behind him. Ms Brooks tried to hip and shoulder Ashley to slow him down and assist the police. She felt Ashley hit her on the left shoulder, like a punch, as he passed her, then he kept running further along the passageway towards the central hub and Coles. Ms Brooks went out to see whether she could still hear a woman screaming and she came across Mr Frost and Mr Jones.

She knew Mr Jones and he told Ms Brooks that he had been stabbed in the shoulder.

Ms Brooks’ shoulder was starting to hurt at this stage, and she asked Mr Jones to have a look at it in case she had been stabbed as well. He confirmed she had. Ms Jones was taken to hospital, where she received stitches to her wound on her shoulder.135 132 Exhibit 1, Tab 22.

133 Exhibit 1, Tab 23 [58].

134 Exhibit 1, Tab 23.

135 Exhibit 1, Tab 24.

[2023] WACOR 38

98. Sergeant Michelle Cornwall136 and Sergeant Michael Little137 were both experienced police officers stationed at South Hedland Police Station in May 2020. They were on duty on the morning of 1 May 2020, working together undertaking summer crime strategy patrols. Both police officers were kitted up in full police uniform, wearing their accoutrements and ‘high vis’ bright yellow Police vests. They drove to the shopping centre at about 9.40 am and went to Kmart as Sgt Little wanted to speak to the Kmart manager about an open inquiry. They had driven there past The Lodge motel but had not seen, or heard, about any incident involving Ashley before starting a foot patrol in the centre and walking to Kmart. Sgt Little was standing outside Kmart talking to the manager, and Sgt Cornwall was standing off to one side a little, when the events involving Ashley drew their attention.138

99. Sgt Cornwall was monitoring the Police radio and heard a call over the radio regarding a stabbing at the Lodge motel. They were the closest police officers so Sgt Cornwall responded over the radio and said they would leave the shops and head that way.

Sgt Little had heard an increase in radio transmissions over the radio, which was a sign that something was happening, but he hadn’t overheard the detail. He ended his conversation with the store manager and began to walk towards Sgt Cornwall. She spoke to Sgt Little and told him they had a job and had to go. Around that time, Sgt Little also began to hear screaming coming from outside the shopping centre entrance. He was not immediately concerned, as sometimes they get noisy teenagers in the centre. However, he then looked in the direction of the noise and saw it was a woman screaming near the shopping centre entrance. Sgt Cornwall and Sgt Little then noticed Ashley enter the shopping centre.139

100. Ashley caught Sgt Cornwall’s attention as he was walking really quickly while holding a kitchen knife in his right hand, held out in front of him. She could see it was a large kitchen chopping knife. Ashley had no real expression on his face and it didn’t appear to Sgt Cornwall that he was really aware of anything around him. Sgt Little saw the woman screaming and then he also noticed Ashley walking intently, although he did not immediately see the knife in his hand. He noticed that everyone else was either standing still or trying to see the source of the screaming, whereas Ashley was walking purposefully towards them and stuck out for that reason.140

101. Ashley continued moving quickly past the two police officers into the middle of the shopping centre, heading towards the central hub. Sgt Cornwall told Ashley to stop and yelled out, “he has a knife.”141 Sgt Little gave evidence that he was piecing information together at that time and though he didn’t see the knife or hear Sgt Cornwall’s reference to it, he heard her directing Ashley to stop and put that with the sound of the woman screaming and assumed Ashley might be involved. Ashley didn’t stop, and instead increased his pace, so Sgt Little began to follow him.142 136 Now Senior Sergeant.

137 Now Brevet Senior Sergeant.

138 Exhibit 1, Tab 28 and Tab 29.

139 T 70, 85; Exhibit 1, Tab 28 and Tab 29.

140 T 70, 85; Exhibit 1, Tab 28 and Tab 29.

141 Exhibit 1, Tab 28 [17] 142 T 87; Exhibit 1, Tab 28 and Tab 29.

[2023] WACOR 38 Sgt Cornwall attempted to manually activate her body worn camera to start recording (although it doesn’t appear it turned on) and then ran with Sgt Little after Ashley.

Sgt Cornwall suspected at that time that Ashley might be involved in the stabbing incident at The Lodge given the time frame and proximity to the area.143

102. Sgt Little managed to catch up to Ashley and it was at that time that he first observed that Ashley had a large knife in his hand. Ashley then increased his pace again. At this stage, Sgt Little said things began to come together and he made a connection between Ashley, the knife and the woman he had heard screaming. He thought it was possible Ashley had been involved in an incident with the woman.144

103. Sgt Little tried to stay parallel to Ashley and match his pace, while Sgt Cornwall took up a position towards the other side and a little behind. Sgt Little and Sgt Cornwall were both yelling out to Ashley, “Police stop, drop the knife.” Ashley started to run through the centre, passing other people and bumping into some of them as he was running. The police were yelling at people to get out of the way, as they were concerned for their safety. Sgt Cornwall saw Ashley get close to Ms Brooks but she wasn’t sure at that stage if he had stabbed her or not. Sgt Little was running faster and so he moved closer to Ashley as they ran. Sgt Cornwall took out her taser, because Ashley was armed. She stated that she chose her taser over her firearm because of the location, people and because they were running and he was running away from them.

In her evidence, Sgt Cornwall said that their preference would have been to just contain Ashley, but that wasn’t possible because he was running.145

104. As Ashley reached the central hub, which was the busier part of the shopping centre, Sgt Cornwall saw Ashley approach a female civilian while holding the knife out.

Sgt Little saw Ashley turn his head towards him and was able to observe Ashley’s face at that time. He recalled Ashley stared vacantly at him and there was no communication, but it also appeared like he was intent or purposeful in what he was doing. Sgt Little was yelling at people to get out of the way. He drew his taser because Ashley was still carrying the knife, which it seemed he may have already used to harm someone, and was ignoring the police commands to stop. After shouting loudly at Ashley twice to drop the knife, Sgt Little then discharged his taser.146

105. Sgt Little was running close to Ashley at that time. He believed the taser probes went into or around Ashley’s back and he saw signs that made him believe it had deployed correctly, but the taser appeared to have no effect on Ashley. His behaviour did not change and he kept running. Sgt Little went to reload and gave himself an accidental shock, before he managed to reload successfully. He then deployed the taser again, but this also appeared to have no effect. Sgt Little shouted out, “Ineffective,”147 in order to let Sgt Cornwall know that the taser did not appear to have worked.148 143 T 70; Exhibit 1, Tab 28 and Tab 29.

144 T 88.

145 T 73, 87 - 88; Exhibit 1, Tab 28 and Tab 29.

146 T 90; Exhibit 1, Tab 28 and Tab 29.

147 Exhibit 1, Tab 29 [101].

148 Exhibit 1, Tab 28 and Tab 29.

[2023] WACOR 38

106. Given the lack of response to the taser, Sgt Cornwall stated that she considered transitioning to her firearm at that time, but she chose not to because they were running and the shopping centre was busy. She also was aware that Sgt Little had just used both of his taser cartridges so he was down to having to use his firearm as his next use of force option. Sgt Cornwall deployed her taser next, but it also had no effect on Ashley. Sgt Cornwall stated she was surprised that after three deployments of the taser, there had been no noticeable effect. Sgt Little had heard the sound of Sgt Cornwall’s taser discharging and he also observed it had no obvious effect on Ashley, although Ashley did turn around, so it is possible one of the probes went in and caught his attention.149

107. Sgt Cornwall saw him turn around and things then changed, as Ashley immediately moved back towards her. Sgt Cornwall was still moving forward at that stage, so the distance between them closed very quickly. Sgt Cornwall stated she was in fear for her life, Sgt Little’s life and the lives of others around them at that stage, as Ashley no longer appeared to be trying to escape, but was instead preparing to confront them.

Ashley turned towards Sgt Cornwall, raised his arm up over his head and then lunged towards her with the knife, saying “I will fucking kill you.”150 Ashley moved his arm in a downward stabbing motion and the hand that was holding the knife connected with Sgt Little’s right shoulder. She was knocked to the ground by the blow. It appeared to Sgt Little from where he was standing that Sgt Cornwall had been stabbed in the neck or shoulder. Sgt Cornwall was initially unsure if she had been stabbed as she was aware that it can initially feel just like a punch, which was the impact she felt.

However, after physically checking her shoulder, Sgt Cornwall called out to Sgt Little that she was okay, but in the moment he didn’t hear her. Based on what he had seen, he believed she had been stabbed and was probably injured.151

108. After knocking Sgt Cornwall to the ground, Ashley had immediately turned around and continued in the same direction towards the population hub area. Sgt Little could see Ashley approaching a member of the public who appeared frozen in place. It appeared to Sgt Little that Ashley was heading directly towards where the woman was standing. Sgt Little drew his firearm and shouted repeatedly to Ashley, “Stop, drop the knife.”152 Sgt Little said he was trying to draw Ashley’s attention towards him and away from the woman, as Ashley and the woman were now only metres apart. Ashley turned around to his left-hand side and looked at Sgt Little, then started moving towards Sgt Little at a fast pace. It appeared to Sgt Little that Ashley was walking towards him with intent and with purpose, while staring at him but saying nothing.

Sgt Little said it became that his words couldn’t penetrate him.153 Sgt Little said, “[t]here was nothing I could do to break down that barrier between us”154 and he had no doubt at that time that Ashley intended to hurt people at that point.

109. When Sgt Little had drawn his firearm, it activated his body worn camera, which also recovers a short burst of footage preceding the firearm being drawn, so some of the 149 T 73 - 74; Exhibit 1, Tab 28 and Tab 29.

150 T 74; Exhibit 1, Tab 28 [42].

151 T 74 – 75, 101; Exhibit 1, Tab 28.

152 T 96.

153 T 96, 103.

154 T 103.

[2023] WACOR 38 earlier events were also captured, along with the ensuing events. Therefore, there is objective evidence of some of these events along with the witness accounts. They show how quickly Ashley turned towards Sgt Little and his purposeful movements towards him.

110. Sgt Little recalled at that time Ashley was holding the knife lower, at about his waistline. It seemed Ashley was concentrating on him and Sgt Little tried to communicate with him. Sgt Little gave evidence he was thinking “If I can just get through to him or something, maybe he can drop the knife, he’s concentrating on me.

Please just drop the knife.”155 Unfortunately, Ashley did not respond and kept coming towards him. Sgt Little recalled looking into Ashley’s eyes as he spoke to him, but Ashley just stared at him with an “intense vacant stare.”156

111. Sgt Cornwall was getting up off the ground when she saw Ashley moving towards Sgt Little. Sgt Cornwall heard Sgt Little yell out to Ashley to drop the weapon, stop or he would shoot, although Sgt Little recalls only yelling out “Drop the knife.”157 Ashley’s attention was clearly focussed on Sgt Little. Other evidence indicates Ashley was making threats to Sgt Little at this time, but in the moment Sgt Little did not recall if he heard Ashley was saying anything as he was focussed solely on Ashley’s movements with the knife.158

112. Ashley was about two or three metres from Sgt Little when he began making motions towards him with the knife and held it up higher. Sgt Little recalled Ashley brought the knife up to about shoulder height, in a similar manner to when he had struck at Sgt Cornwall. He then charged towards Sgt Little with the knife raised in a lunging action. Sgt Little said in evidence, “I believed I was next at that point”159 as it seemed the knife was aimed towards him the way it had been aimed at Sgt Cornwall. Sgt Little said he felt at that point that he had no other choice, so he pulled the trigger and fired one shot, aiming for centre of mass to stop the threat. The shot appeared to have no effect at all.160

113. At around the same time, the security manager from the shopping centre, who had been standing behind the police, unexpectedly entered the frame and tried to push Ashley to the ground with both hands. Ashley shrugged him off and the security manager then fell over, while Ashley remained unaffected. The police officers didn’t even register the security manager in the moment, as their focus remained on Ashley and the threat he continued to present.161

114. It was unclear at that stage to the police officers whether the shot had hit Ashley or missed (although Sgt Little thought his shot was accurate), as Ashley didn’t appear affected. He kept walking very quickly towards Sgt Little, still holding the knife in the same position. Sgt Little was moving backwards, to try to increase the gap between

155 T 97.

156 Exhibit 1, Tab 29 [120].

157 Exhibit 1, Tab 29 [109].

158 Exhibit 1, Tab 29.

159 T 97.

160 T 97 – 98; Exhibit 1, Tab 29.

161 T 98; Exhibit 1, Tab 28 and Tab 29 and Tab 30.

[2023] WACOR 38 them, but there was nowhere to move back to as they were now in the main concourse of the shopping centre and he didn’t know how much room he had behind him.

Sgt Little was also still yelling out to Ashley, without any response.162

115. As the distance between them decreased, Sgt Little made a decision to fire a second shot. Despite Sgt Little being confident his shot was accurate, Ashley again continued to move towards Sgt Little with no apparent effect from the gunshot. Ashley was still holding the knife while saying he was going to kill him. Sgt Little was moving backwards, still trying to create distance between himself and Ashley, when he fired the third and final shot. The effect was instantaneous. Ashley immediately fell to the ground. Sgt Cornwall had been trying to reload her taser at this time, to give them the option of using a taser again if the opportunity presented itself, but it was all over in seconds.163

116. Ashley still had the knife in his hand, so Sgt Little removed the knife from his hand with his foot and re-holstered his firearm. At that moment, Ashley was no longer assessed as a threat. Sgt Little stated his first thought in that moment after was, “this guy who was so intent on causing me harm is now vulnerable and needs my help.”164 Sgt Little and Sgt Cornwall immediately moved to providing emergency first aid to Ashley. Sgt Cornwall holstered her taser, radioed the station to request an ambulance be sent Priority 1 and they then opened Ashley’s shirt to try to identify any wounds and apply pressure where needed. Sgt Cornwall had called out to members of the public to bring first aid equipment and some people came to help, bringing first aid kits and other medical aids.165 While holding Ashley’s head in his hands, Sgt Little began talking to Ashley, saying, “Stay with me. Stay with me. We’re getting you help.”166 Sgt Little felt like Ashley was looking directly at him, but he could see in Ashley’s eyes that he was dying.167

117. Two registered nurses were in the shopping centre that morning. They both came to help after realising someone had been shot. The two police officers and a Coles staff member were already providing first aid to Ashley using a medical kit and defibrillator brought from the Coles store. They were trying to apply pressure to his wounds and provide reassurance to Ashley. Ashley still had a pulse at this stage, although it was fast and fluttering and he was obviously losing a lot of blood. One nurse noticed that soon after she arrived, Ashley’s breathing began to change to a style of breathing that indicates imminent demise. Ashley stopped breathing about 30 seconds later. They applied the defibrillator and then commenced CPR, with a police officer still applying pressure on the wounds.

118. When other police officers arrived, Sgt Little said he “had never felt so relieved”168 and he let them take over helping Ashley along with Sgt Cornwall and the nurses.

They continued two full cycles of CPR while the defibrillator analysed the rhythm. A 162 T 75, 98 - 99; Exhibit 1, Tab 28.

163 T 77, 99; Exhibit 1, Tab 28 and Tab 29.

164 Exhibit 1, Tab 29 [155].

165 Exhibit 1, Tab 28.

166 Exhibit 1, Tab 29 [157] 167 T 100; Exhibit 1, Tab 29.

168 Exhibit 1, Tab 29 [168].

[2023] WACOR 38 face mask was applied to Ashley and he was given intermittent breaths, before they administered a third cycle of CPR. After completing the third cycle, it appeared to the two nurses that Ashley’s injuries were inconsistent with life and he had died, so they agreed in consultation that they should cease all resuscitation efforts and declared Ashley life extinct. The ambulance arrived 5 or 10 minutes later and the nurses advised the SJA officers that they had already declared the death. One of the ambulance officers applied a heart monitor, which confirmed Ashley’s heart had stopped. A formal Certificate of Life Extinct Form was completed by a SJA paramedic at 10.25 am.169

CAUSE OF DEATH

119. Two Forensic Pathologists, Dr C.T. Cooke and Dr R.C. Junckerstorff made a postmortem examination on the body of Ashley on 6 May 2020. The examination showed three gunshot wounds to the front of the torso: one to the front of the right shoulder, the second to the right side of the chest with associated internal injury to the right lung and an exit wound, and the third to the chest and abdomen, with internal injuries to the heart, diaphragm and liver. There was early, localised narrowing of one of the arteries on the surface of the heart (early, focal coronary arteriosclerosis). The body organs appeared to be otherwise healthy, including the brain.170

120. Toxicology analysis showed the presence of two medications, at non-toxic levels.

Alcohol and other common drugs were not detected.171

121. At the conclusion of all investigations, the forensic pathologists formed the opinion the cause of death was gunshot injuries.172 I accept and adopt the forensic pathologists’ opinion as to the cause of death.

REVIEW OF POLICE CONDUCT

122. The circumstances of Ashley’s death, involving a police officer discharging a firearm resulting in the death, fell within the WA Police policy definition of a ‘Critical Incident Involving Police.’173 Accordingly, a joint investigation was commenced by the Major Crime Division in coordination with the Internal Affairs Division (IAU).

Homicide Squad investigated the circumstances surrounding the fatal police shooting to assess whether there was any criminality in the conduct of Sgt Little discharging his firearm and causing Ashley’s death and whether the police officers’ conduct was lawful and justified and excused by law. The Internal Affairs Unit assessed whether any breaches of WA Police Policy or Procedure occurred on the part of both officers involved.

123. Both Sgt Little and Sgt Cornwall were interviewed as part of the IAU investigation and provided statements. A large number of other witnesses were also spoken to and a 169 Exhibit 1, Tab 2 and Tab 24 and Tab 26.

170 Exhibit 1, Tabs 5, 6 and 8.

171 Exhibit 1, Tab 5 and Tab 7.

172 Exhibit 1, Tab 5.

173 Exhibit 2, Tab 1, p. 5 - CP 0.100; Critical Incident Involving Police.

[2023] WACOR 38 significant amount of physical evidence was obtained, including the body worn camera video footage from both involved police officers, CCTV footage from the shopping centre and other businesses/agencies that depicted most of Ashley’s actions and the firearm, bullets and fired cartridge cases involved. Ashley’s family were also interviewed to obtain relevant background history and Ashley’s medical history was explored.174

124. The body worn camera footage of the two police officers was described as some of the “most crucial bits of evidence,”175 as it corroborated what had been stated by the witnesses and police officers about the events.

125. From the statements and objective camera footage from the police and shopping centre, it was apparent that although they were both clearly identifiable as armed police officers, Ashley did not respond to their commands to drop his weapon. Both officers described Ashley’s vacant stare, which suggested he was not mentally in a state where he was processing what was around him. Sgt Cornwall stated that at the time they were trying to engage with Ashley, it appeared to her that he might be “off medication suffering from mental health rather than affected by methylamphetamine.”176 This was because, from her experience, Ashley did not exhibit the right signs or level of agitation to be drug affected, but it was obvious he was behaving in an abnormal manner.177

126. Both Sgt Cornwall and Sgt Little gave evidence they were in fear for their own lives and for the lives of others, given Ashley’s behaviour and the fact he was armed with a deadly weapon. Sgt Little stated that at the time he fired the first round, he thought, “If I don’t make the decision now, it’ll be too late.”178 When he fired the second round, Sgt Little thought, “It was him or me.”179 After firing two rounds, Ashley was still charging at him and it felt to Sgt Little like he was firing blanks as neither round had any effect on him, despite the fact he was confident he had hit the target each time. He wondered for a moment whether Ashley was wearing a ballistic vest under his clothes, before he fired the third round. The effect of the third shot was, however, instantaneous. Sgt Little stated that he “immediately was so relieved that he stopped”180 and holstered his firearm while everything seemed to slow right down.

127. Sgt Little said he was confused and afraid at that time that one of his shots might have gone astray, given the lack of response by Ashley to the first two rounds, so he asked other police officers who arrived to check for him that no one in a nearby shop had accidentally been harmed by his actions. They checked immediately and, to his relief, reported back to Sgt Little that everyone was okay. Sgt Little was taken back to the station and, while undergoing a forensic examination, he was informed of Ashley’s death. He asked at the time, “Is anyone else dead?” and was told, “No.”181 He didn’t find out until much later all of the events involving the other people that morning, but

174 T 108 - 109.

175 T 109.

176 Exhibit 1, Tab 28 [71].

177 Exhibit 1, Tab 28.

178 Exhibit 1, Tab 29 [133].

179 Exhibit 1, Tab 29 [139].

180 Exhibit 1, Tab 29 [151].

181 Exhibit 1, Tab 29 [186] – [187].

[2023] WACOR 38 he had been concerned at an early stage that someone else may have been harmed given the screaming he had heard around the time he first saw Ashley. Given the number of people Ashley encountered and the fact he actually stabbed six people with a large knife, in hindsight it seems very fortunate that there were no other deaths arising from this terrifying and tragic incident.182

128. Expert ballistics evidence was obtained from an officer from the Forensic Firearm Unit183 to assist the investigators from Homicide Squad and also a subject matter expert in ‘Use of Force’184 provided advice to assist IAU to reach their determinations as to whether the police officers’ conduct was reasonable and proportionate, and also to assist the Coroners Court.

129. Mr Christopher Markham is the capability adviser on use of force used by the WA Police in this case. Mr Markham is a former police officer with the UK Police and senior instructor with the WA Police. He currently works at the WA Police Academy within the Occupational Safety and Tactics Training Unit as the Senior Capability Advisor - Use of Force for the Operational Skills Training Faculty. He is a subject matter expert for use of force, particularly in relation to tasers but also in relation to other force options available to police officers. Mr Markham oversees the use of force for the agency, so any time an officer is involved in a ‘use of force incident,’ Mr Markham will review those incidents and provide an opinion, as well as being available for any related judicial proceedings.185

130. Mr Markham prepared a report dated 17 March 2023, in which he carefully considered all of the evidence related to the use of force by Sgt Cornwall and Sgt Little, in the form of their use of tasers and a firearm as tactical options against the threat posed by Ashley on the day. In particular, Mr Markham looked in detail at the vision recorded by both police officers’ body worn cameras, CCTV footage from the shopping centre and the event log data downloaded from the tasers. Although the body worn cameras were only activated at the time Sgt Little drew his firearm, the cameras are designed with a thirty second vision (no audio) back capture capacity186 if they are in standby mode, so they captured vision of the period of time leading up to the removal of the firearm from the holster, as well as the discharge of the firearm. This resulted in the footage also capturing the taser deployment, as all of these events occurred within thirty seconds of Sgt Little drawing his firearm from its holster.187

131. The body worn camera vision shows how quickly the events occurred, indicating that:188

• between 9:55:22 and 9:55:42, Sgt Little deployed his taser twice and Sgt Cornwall deployed her taser once, with each deployment ineffective;

• at around 9:55:49, Sgt Little drew his firearm;

182 T 105.

183 Exhibit 1, Tab 45.

184 Exhibit 3, Tab 3.

185 T 126 – 127.

186 Exhibit 3, Tab 3, p. 95.

187 T 132; Exhibit 3, Tab 3.

188 Exhibit 3, Tab 3, p. 115 - 117.

[2023] WACOR 38

• at 9:55:50 Ashley stopped and turned;

• at 9:55:51 Ashley started advancing towards Sgt Little, while shouting, “I’ll kill you”;

• at 9:55:52 Sgt Little discharged the first round - there was no apparent effect on Ashley and he continued to move towards Sgt Little while shouting threats;

• at 9:55:55 Sgt Little discharged the second round – there was again no apparent effect on Ashley and he continued to move towards Sgt Little while shouting threats;

• at 9:55:57 Sgt Little discharged the third round – Ashley was less than two metres from Sgt Little at this time and still running and making threats – but he then almost instantaneously collapsed to the ground.

As can be seen from the above, almost all of the key interactions between the police and Ashley took place in a total of 35 seconds, before Ashley fell to the ground.189

132. Having reviewed all relevant materials closely, Mr Markham described the situation faced by the two police officers as “dynamic and unpredictable from the outset.”190 They were unaware of the number and nature of incidents that had occurred leading up to Ashley entering the shopping centre, but it was apparent from the moment they saw him that he presented as an imminent “mobile and lethal threat”191 to members of the public and the two police officers. Failure to intervene decisively and rapidly would have increased the risk that other innocent persons would be harmed, particularly given the busy shopping centre environment. There was no opportunity to cordon and contain Ashley, and when he failed to stop and obey their commands, it was necessary for the two police officers to take action to try to reduce the threat and gain control of Ashley.192

133. At the time Sgt Little fired three shots at Ashley, he was a direct threat to him.

Although Ashley was not within immediate striking distance with the knife, he was advancing and closing the distance between them quickly in circumstances where Sgt Little’s ability to retreat was limited. After each shot, he took a couple of seconds to assess whether the shot had stopped the threat, but each time it was clear Ashley had not been incapacitated and the threat remained. It was only after the third shot that the threat had diminished to a safe level, and Sgt Little immediately holstered his firearm and Sgt Cornwall holstered her taser.193

134. Mr Markham concluded that the actions of the two police officers, namely:

• the use of tasers twice by Sgt Little and once by Sgt Cornwall; and

• the use of a firearm, discharged three times, by Sgt Little; were all justified and in accordance with relevant legislation and the WA Police Force policy, training and guidelines.194 189 Exhibit 3, Tab 3, p. 121.

190 Exhibit 3, Tab 3, p. 117.

191 Exhibit 3, Tab 3, p. 118.

192 Exhibit 3, Tab 3, pp. 117 – 119.

193 T 148 - 149; Exhibit 3, Tab 3, pp. 117 – 119.

194 Exhibit 3, Tab 3, p. 119.

[2023] WACOR 38

135. In terms of the Homicide Squad investigation, conducted under the name Operation Aten, the Senior Investigating Officer, Detective Senior Sergeant Sean Wright, noted it was unequivocal that Sgt Little fatally shot Ashley. The investigation focussed on establishing if lethal force was a reasonable response and lawful response in the circumstances, with particular consideration given to ‘self-defence’ under s 248 of the Criminal Code (WA). The Homicide Squad investigation concluded that based on all the evidence, and noting that Ashley was holding a knife, the attack by Ashley upon Sgt Little gave rise to a need for Sgt Little to defend himself (and others) in the manner he did and he acted in self-defence pursuant to s 248 of the Code when he killed Ashley and his conduct was lawful. Accordingly, no criminal charges were laid against Sgt Little in relation to Ashley’s death.195 There was also no criminality established in relation to any of Sgt Cornwall’s conduct on the day. These decisions were reviewed and approved by an Assistant Commissioner.196

136. The IAU investigation examined the actions of both police officers to determine any non-compliance with the WA Police Force policy and the Code of Conduct, with some relevant information provided by the Homicide Squad and close consideration of Mr Markham’s advice. Acting Detective Superintendent Simone Van Der Sluys advised the Coroners Court on 10 May 2023 that the IAU investigation had determined that there was no criminal culpability attached to the actions of either Sgt Little or Sgt Cornwall and the involved officers did not breach WA Police Force Policy or Code of Conduct.197 Detective Sergeant Nesib Uzonovic was the primary investigator in the IAU investigation and gave evidence at the inquest in relation to the investigation and final report. Det Uzonovic confirmed in his evidence that after critically looking at the conduct of both officers, including whether other less lethal use of force options might have been available or whether the officers could have tactically disengaged or cordoned and contained, it was his view that both police officers’ actions aligned with WA Police policy, procedure, training and guidelines, in particular in relation to use of force.198 Det Uzonovic commented that the case, while tragic, appeared to “be a textbook use of force.”199

137. It was clear from their evidence that both Sgt Little and Sgt Cornwall were faced with a sudden threat that unfolded and then ended in less than a minute. A lot of things happened in a very short period of time. However, the effect of the actions and decisions they made in that short period of time is ongoing. Both police officers involved in this matter are still operational members of the WA Police Force and they have been supported throughout the investigation and inquest by other members of the Police Force. They have been cleared from any criminal sanctions or misconduct proceedings, but they both have to live with the memories of what occurred and their roles in it.

138. Sgt Cornwall gave evidence at the inquest and indicated she had thought about these events a lot in the intervening years and the only other thing she thought they could 195 T 109 – 100; Exhibit 1, Tab 9.1, pp. 10 – 11.

196 T 110.

197 Exhibit 3, Tab 2; Exhibit 3, Tab 1.

198 T 116.

199 T 118.

[2023] WACOR 38 have done differently was to use lethal force earlier. She indicated it was a difficult thing to have been involved in the shooting death of a civilian, but was quite clear to her on reflection that they had been left with no other option that morning.200

139. Similarly, Sgt Little said that at the time he fired each shot, he had weighed up in his mind whether each round was justified. He waited briefly after each shot to see if there was an effect, but the first two times, there was none. At the time, and on reflection, he believes each round dispensed was justified as the threat from Ashley remained. As soon as the third shot took effect, Sgt Little immediately holstered his weapon and began first aid. In terms of whether there was any alternative course of action he could take that day, Sgt Little said frankly at the inquest that it, “is a question that has haunted me for three years … and it is probably a question that will continue to haunt me, but there is nothing that I could have done differently that day.”201

MANNER OF DEATH

140. I note the conclusions of the WA Police Homicide Squad and IAU investigations that Sgt Little acted lawfully and in accordance with WA Police Force policies, procedures and training when he fatally shot Ashley in the course of his duty. No further evidence was presented at the inquest that would contradict that view. I have weighed up all of the evidence before me and I am satisfied that Sgt Little acted within the bounds of his training and in self-defence and the defence of others when he shot and killed Ashley.

Accordingly, I find that Ashley died as a result of lawful homicide.

COMMENTS ON PSYCHIATRIC TREATMENT

141. As noted above, Ashley had a known history of psychosis and had previously been an involuntary patient in 2019 and placed on depot antipsychotic medication. At the time of his death, Ashley had transitioned to voluntary patient status and had been receiving his depot medication in the community for a period before he ceased engaging with the service and attending for his depot medication injections. As a result, he was discharged from the service. Given that he then appears to have suffered a significant deterioration in his mental health and suffered a relapse of psychosis, resulting in these tragic events, it was appropriate to consider the standard of the psychiatric care provided to Ashley prior to his death and consider whether Ashley’s psychiatric care should have been managed differently, and whether this could have changed the course of events.

142. Dr Antony, who was the last psychiatrist to review Ashley, was asked, in hindsight, whether he felt different decisions should have been made in relation to Ashley’s psychiatric care prior to his death. In particular, the question was asked whether Ashley should have been managed on a Community Treatment Order (CTO) in order to ensure he continued to receive his depot medication regularly. Dr Antony indicated

200 T 81.

201 T 102.

[2023] WACOR 38 there were no concerns in late 2019/early 2020 that would have warranted Ashley being placed on involuntary treatment and a CTO. He was not displaying any signs or symptoms suggestive of a relapse of his mental illness and there was no apparent risk of harm to himself or anyone else at that stage. This also negated any obvious need to ask the police to do a welfare check on Ashley in March 2020 when he could not be engaged by the service.202

143. As noted above, Dr Antony explained that once Ashley stopped attending appointments, it was not an option to simply change him to involuntary patient status and put on a CTO, as he would have to be assessed face-to-face before such a decision could be made.203

144. Although he had no further contact with Ashley after December, Dr Antony expressed the opinion the attempts by the staff from the clinic to re-engage Ashley before his discharge were reasonable, although he did not recall being consulted before Ashley was discharged. Dr Antony suggested a couple more steps could have been taken around that time to flag Ashley with other health service providers, such as contacting his GP and putting an alert on PSOLIS, but in Dr Antony’s view, these steps were highly unlikely to have affected Ashley’s treatment, the decision to discharge him from the service or the ultimate outcome. Ashley needed to respond and engage with the service, and when he did not, a decision had to be made at some stage to discharge him, which would allow the clinic to engage with another patient. The service was stretched due to COVID-19, which meant they needed to ensure that all of their patients required, and were responding to, ongoing treatment and support. Dr Antony noted that Ashley could have re-engaged with the health service at any time, even after discharge, if he had wished.204

145. Dr Georgina Dell was the Acting Head of Service for Mental Health for the Armadale Health Service at the time of the inquest. Dr Dell gave evidence at the inquest that she had reviewed the care provided to Ashley whilst he was under the care of Eudoria Street Clinic and in her opinion it was appropriate. Dr Dell expressed the opinion that Ashley would not have qualified for a community treatment order as he did not meet the criteria under the Mental Health Act at the time he was engaging with the clinic. In particular, at the time he was being assessed by Dr Antony in late 2019 and then followed up by other clinic staff in early 2020, he appeared to have capacity to make treatment decisions and did not present as a severe risk to himself or others. Generally, he had only ever appeared to present a risk to himself, even when unwell. Dr Dell expressed the opinion that it appeared from the notes that the clinic staff had done everything they could to engage Ashley back with the service, but as a voluntary patient he was entitled to choose to stop attending appointments and, by March 2020 they had to make decisions about resources and what they needed to focus on. Given Ashley’s disengagement and the fact he seemed to be in remission and was assessed at low risk, Dr Dell expressed the opinion Ashley was appropriately discharged.205 202 T 24; Exhibit 1, Tab 48.

203 T 19.

204 T 23; Exhibit 1, Tab 48.

205 T 155 – 161, 164 - 165.

[2023] WACOR 38

146. In terms of disclosing Ashley’s diagnosis and medical care to any persons, Dr Dell noted that Ashley had given his treating team permission to discuss his care with his parents, and she was aware there were discussions with Ashley’s parents at various times, including prior to his discharge from the service. The notes indicate Ashley’s parents thought he was not getting his depot and they were concerned as they believed he benefited from the depot medication. The staff were also aware Ashley had moved out of the family home. In the circumstances, one might think that it would have been helpful for his treating team to give information to Ashley’s new housemate and work colleagues about his condition and warning signs to look out for if he relapsed.

However, that would only have been possible if Ashley had given his consent, which was never discussed with him. Ashley had the right to patient confidentiality unless there was an identified risk to a particular person, so it was up to him what information he wanted to disclose to friends and colleagues. Ashley obviously did choose to discuss in more detail his mental health issues with Michael Sopp, but with his employer and colleagues he chose to share only some of his circumstances. While that was his right and understandable, unfortunately it meant that when Ashley began to relapse away from home, the people around him were not able to identify the warning signs.206

147. Dr Adam Brett is a very experienced Forensic Consultant Psychiatrist who has provided an expert opinion in many coronial cases, as well as working in the Magistrates’ Mental Health Court (or Start Court) and providing expert reports for other courts in Western Australia. Dr Brett was asked by the Court to review Ashley’s case and provide an opinion on Ashley’s mental health management leading up to his death. Dr Brett provided a report and also gave evidence at the inquest.207

148. Dr Brett agreed that Ashley’s history was consistent with schizophrenia with depression, with his mental health deteriorating following the break-up of his marriage. Dr Brett noted that Ashley had been managed on one occasion in hospital as an involuntary patient, but with treatment he was made a voluntary patient and the rationale for this was clearly spelled out in the hospital discharge summary. He was commenced on depot antipsychotic medication and agreed to take it on a voluntary basis. There was good documentation that he responded well to this medication and went into remission.208

149. The problem arose when Ashley became reluctant to continue taking his depot medication. Dr Brett noted that Ashley had been assertively followed up in the community as a voluntary patient and when he complained of side effects from his medication, it was reduced and side effect medication was added. When he complained about his doctor, a second opinion was organised. It seemed, therefore, that the treating team made efforts to engage Ashley and accommodate his requests, with the aim of keeping him compliant with his treatment.209

150. Despite these efforts, Ashley still became non-compliant with his treatment, missing appointments in late 2019 before seeing Dr Antony in December 2019 for a second 206 T 157 – 158, 163- 164; Exhibit 1, Tab 47.

207 Exhibit 1, Tab 46.

208 Exhibit 1, Tab 46.

209 Exhibit 1, Tab 46.

[2023] WACOR 38 opinion, which was the last appointment Ashley attended. At that time, he was documented as being in remission, with no evidence of ongoing mental disorder. This was consistent with the evidence of his parents and friend, who overall thought Ashley seemed well and looking forward in April 2020. His risk assessment was low at the time he was discharged from the clinic on 26 March 2020 due to lack of contact and no significant risk issues.210

151. Dr Brett said he believed Ashley’s management was appropriate and the quality of the mental health care he received was good given the resources available in WA for these services. There was good documentation and good liaison with Ashley’s GP and family. His case manager made significant efforts to follow him up in the community, including telephone calls and home visits. Ashley’s concerns about his medication were listened to and attempts were made to work with him to resolve some of those issues. Unfortunately, these attempts were not sufficient to convince him to continue engaging with the service and taking his depot medication.211

152. Dr Brett acknowledged that Ashley responded well to his depot medication, but consistent with the opinions of Dr Antony and Dr Dell, Dr Brett did not believe that Ashley should have been placed on a CTO when he refused his depot medication.

Ashley had been documented as having the capacity to make treatment decisions at the time of his discharge from hospital, he did not have significant risk factors and he was functioning well and back at work. He did not have a long history of contact with mental health services and had had one previous episode of non-compliance and his subsequent relapse was quickly picked up. Dr Brett commented that it appeared appropriate to discharge Ashley from Armadale clinic’s care after they had tried to engage him and failed.212

153. Ashley was well when he was discharged from the service, but he stopped his medication so he was an increased risk of relapsing. However, that could not be taken into account in the decision to discharge him after he stopped being willing to engage.

It is apparent now that Ashley did relapse after some months off his depot medication.

He last received it in December 2019, so by 1 May 2020 Ashley had been off his medication for around four months. While it is a long-acting psychotic and remains in the system for some time, Dr Brett gave evidence that it slowly reduces over time, which meant Ashley probably had a slow deterioration over those months. However, the events on the day he died strongly suggested that by that time, Ashley had suffered a significant relapse of his schizophrenia. Dr Brett commented that Ashley’s change in presentation so rapidly was unusual and his relapse in those circumstances was extremely unpredictable.213 On the day, Dr Brett expressed the opinion Ashley was likely to have been “in a delusional world which other people couldn’t access.”214 Dr Brett’s impression from Ashley’s behaviour was that Ashley was fearful for his own life and fearful he might be harmed by others, and he seemed to be acting in response to that fear based upon the delusions he was experiencing.215 210 Exhibit 1, Tab 46.

211 T 169, 172; Exhibit 1, Tab 46.

212 Exhibit 1, Tab 46.

213 T 173 - 175.

214 T 176.

215 T 175 – 176.

[2023] WACOR 38

154. Dr Antony agreed that based upon the evidence of Ashley’s behaviour on the day of his death, and noting Ashley had no drugs or alcohol in his system, he “would draw the conclusion that he was quite unwell at the time.”216 Dr Antony commented that it was really unfortunate that Ashley went off his treatment, as he had been doing well on his medication. If he had been taken to hospital and psychiatrically assessed, steps could have been taken to then make him an involuntary patient and put him back on his medication, as had happened before, but unfortunately Ashley died before this could occur.217

155. Dr Brett noted that Ashley’s relapse was theoretically preventable but it required Ashley to be willing to take his depot medication voluntarily at that stage. Dr Brett acknowledged that there are a lot of known side-effects to antipsychotic medications.

Dr Brett commented that it is a balance between the benefits of the medication and the negatives of the side-effects, which is why patients need ongoing education in a way they can process, so that they understand the risks of stopping the medication and relapsing. Dr Brett noted that schizophrenia is a very difficult disorder to manage, which should not be forgotten when considering the facts of this case, and why peer support workers with lived experience can be a very useful support.218

156. Dr Brett provided a copy of A Practical Guide for Working with Carers of People with Mental Illness and gave evidence that there needs to be a change in culture in mental health services so the individual and the family and other support people are central to the care of clients and support workers and peer/family support workers are embedded in the system. Dr Brett suggested there needs to be care support workers or peer support workers as an integral part of the clinical team, who are then able to act as a liaison between families and other staff to improve patient care. Dr Brett indicated his understanding is that the providers of the State’s mental health services and the Mental Health Commission and Chief Psychiatrist are all supportive of the concept, but it still has some way to go to be integrated into practice broadly and to be embraced by the mental health system.219

157. Ashley’s parents indicated that, despite Ashley giving his doctors and other treating practitioners permission to discuss his case, they felt they were essentially “kept in the dark”220 about how he was progressing in terms of treatment in the clinic. Dr Brett noted this was an example of how Ashley’s parents were being talked to, but obviously they were not getting the information they needed, or in a format that helped them understand what Ashley needed. A family support worker or peer support worker with lived experience could help to communicate the information in a way that is better understood and ensure that the family are properly engaged. Dr Brett gave evidence that such workers are integral to the work of the Start Court, and in his clinical experience their inclusion has been the “biggest game changer”221 he has seen

216 T 26.

217 T 26 – 27.

218 T 179 - 180.

219 T 170, 178; Exhibit 4.

220 T 168.

221 T 171.

[2023] WACOR 38 in his many years of practice in mental health, improving both care and levels of satisfaction.222

158. They expressed support for Dr Brett’s suggestion of a more comprehensive mental health service that ensures that carers are more engaged in the care in a more structured way. I note Dr Dell was supportive of this concept, but noted it is a “matter of resourcing and having the underpinning mental health system that can support this structured approach,” which would be difficult at the present time given the stretched resources across all of the mental health services in WA, including Armadale Mental Health Service.223 Dr Dell noted that at the time of the inquest, Armadale Mental Health Service had started up a new community home treatment team service that includes a peer support worker, but they had struggled to start the new service due to issues with recruiting appropriately qualified staff, in particular consultant psychiatrists.224

159. Ashley’s employer, Mr Italiano, and supervisor, Mr North, had both given evidence they wished they had known a little bit more about Ashley’s mental health history as they believe if they had known that he had stopped taking anti-psychotic medication, it might have helped them to understand why Ashley was behaving out of character and perhaps led them to take him to hospital, rather than back to the hotel.225 Dr Brett also suggested the issue surrounding Ashley’s patient confidentiality and his work situation should preferably have been discussed by his treating team to encourage Ashley to have that discussion with his employer/colleagues, particularly given he was flying in and flying out of places and not taking his medication, as he was increasing his risk of relapse. However, it would still have remained Ashley’s choice as to how much information he disclosed. Dr Brett also commented that it appeared Ashley had presented very well until just before the final events unfolded, so it may have been that even with information, his work colleagues would not have done anything differently.226 Dr Brett expressed the view that Ashley’s relapse and the sudden violent events that ensued was “a terrible tragedy which wasn’t predictable.”227

160. After the conclusion of the inquest hearing, I was provided with some additional information from Dr Lesley Bennett, the Acting Chief Executive of the East Metropolitan Health Service, which encompasses Armadale Hospital and the Eudoria Street Centre.228 Dr Bennett advised that EMHS is supporting the introduction of a peer support program as part of the Mental Health Commission’s Lived Experience (Peer) Workforce Framework, which is intended to aid in growing a workforce of peer support workers with lived experience of mental health, alcohol or other drug issues in order to assist patients and their families/carers/support persons by advocating, advising, representing and supporting their peers within services. EMHS is developing a strategy to incorporate lived experience (peer) support workers into the service, including the creation and recruitment of a Peer Support Coordinator and then the

222 T 171.

223 T 167.

224 T 162 – 163, 167.

225 T 43, 55, 57-58.

226 T 177.

227 T 182.

228 Letter from Dr Bennett – EMHS dated 16 June 2023.

[2023] WACOR 38 creation of a Crisis Resolution Home Treatment Team, which will provide mental health treatment in the home and will include peer support roles. By June 2023, a peer support worker had already been recruited for the Armadale location and recruitment was underway to recruit for two other locations in the EMHS area. Training for other staff was also planned to provide information about peer support workers and how they can be embedded into the organisation.

161. Given Dr Brett’s own positive experience of working with peer support workers in the difficult arena of the Start Court, I anticipate the involvement of peer support workers in the home treatment of mental health patients involved with EMHS will be received positively by staff, patients and their families, carers and supporters. I hope Ashley’s family and friends take comfort in knowing that the health system is continuing to learn from experience about what changes they can make to better involve caregivers and supporters in the long-term treatment of mental health patients. It was clearly a source of frustration and disappointment for Ashley’s parents in particular that they did not always feel they had a good understanding of what was happening in Ashley’s care, so I have no doubt they support the addition of a peer support worker to the current system, with the hope that it will be expanded further as its value becomes further understood.

CONCLUSION

162. Ashley was a very loved member of his family and his behaviour on the day of his death was completely out of character. Ashley had no prior history of violence and was generally kind, loving and focussed on helping people whenever he could, not hurting them. It is clear his behaviour on this fateful day was a product of his mental illness and he was not his usual self. However, it must also be acknowledged that for the people who were the target of Ashley’s erratic and aggressive behaviour on that day, it was a terrifying experience. This includes the people who were stabbed and the police officers who were put in fear for their lives and forced to make difficult choices that I am sure will live with them for the rest of their careers.

163. Ashley’s parents, Jenni and Lester, and the mother of his child, Tanya, all attended the inquest and heard firsthand about the difficult situation faced by the two police officers that day, with everything happening in seconds. They listened respectfully to the evidence and responded to the witnesses with understanding and kindness despite their own heartache.

164. At the end of the inquest, Tanya shared with the Court her positive experience with the detectives who had liaised with her in the days following Ashley’s death and she wanted all of the police officers involved to know that Selena holds no fear of police and is well supported and well adjusted, despite the traumatic loss of her father. Tanya thanked the police for their services to the community and expressed the hope that the two officers involved can now move on and heal.229

165. Ashley’s parents wanted the Court to know about Ashley as the person he usually was when he was well, and to learn lessons from their difficult journey with Ashley as he 229 Exhibit 1, Tab 50.

[2023] WACOR 38 struggled with adjusting to living with a mental illness and its treatment. Ashley’s parents provided a statement at the inquest in which they expressed their despair at watching their happy son with a big personality and an infectious laugh change in only a couple of years to a “hunched over person rocking from foot to foot” who was eventually shot dead by police. They have struggled to pinpoint where things went so wrong, but know that his reluctance to receive his medication is not unusual for schizophrenia patients and they wish more could have been done to keep him engaged by perhaps offering other solutions. The introduction of peer support workers into the mental health system may well be one way that this could be achieved for other people in the future, although sadly for Ashley it is too late.

166. Ashley’s family ask that we remember him now not for his actions on that one day when he was sick and not himself, but as the person he usually was: a great dad and a gentle, generous and kind man to his friends and family.230 They have extended forgiveness and understanding to the police officer who took Ashley’s life and ask that we as a community extend the same kindness and understanding to Ashley. With that in mind, I have included at their request a photograph of Ashley when he was well and at his happiest. This was the man they knew and loved, and serves as a reminder of what a toll mental illness can have on a person and their family, and why properly resourcing and improving mental health services in Western Australia for the future is so important for our community.

S H Linton Deputy State Coroner 20 October 2023 230 Exhibit 1, Tab 49.