Deceased
Matthew James Worthington
Demographics
male
Coroner
Deputy State Coroner Linton
Date of death
2020-11-24
Finding date
2023-07-18
Cause of death
Gunshot injury to the head
AI-generated summary
Matthew Worthington died from a self-inflicted gunshot wound to the head during a 21-hour police siege at his home in Bayswater, Western Australia, on 24 November 2020. He was experiencing a relationship breakdown, had recently lost his father, was using methamphetamine, and had threatened his former partner with a firearm. Police implemented a 'contain and negotiate' strategy with experienced negotiators who reported that Matthew appeared calm and likely to surrender. The gunshot was completely unexpected, occurring during negotiations with no prior warning. The coroner found the police response was appropriate and professional, with negotiators showing skill and restraint. No adverse comments were made regarding police conduct. The coroner commended the police de-escalation and negotiation approach, noting this strategy successfully resolves incidents in most cases. Matthew's death highlights the unpredictability of individuals under psychological and drug-related stress.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
[2023] WACOR 27 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON, DEPUTY STATE CORONER HEARD : 18 - 19 APRIL 2023 DELIVERED : 18 JULY 2023 FILE NO/S : CORC 2627 of 2020
DECEASED : WORTHINGTON, MATTHEW JAMES Catchwords: Nil Legislation: Nil Counsel Appearing: Mr J Tiller assisted the Coroner.
Ms P Femia and Ms A Kildera (State Solicitor’s Office) appeared on behalf of the WA Police Force.
Case(s) referred to in decision(s): Nil
[2023] WACOR 27 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Deputy State Coroner, having investigated the death of Matthew James WORTHNGTON with an inquest held at the Perth Coroner’s Court, Court 85, CLC Building, 501 Hay Street, Perth on 18 to 19 April 2023, find that the identity of the deceased person was Matthew James WORTHNGTON and that death occurred on 24 November 2020 at Royal Perth Hospital from a gunshot injury to the head in the following circumstances:
[2023] WACOR 27 SUPPRESSION ORDER On the basis that it would be contrary to the public interest, I make an order under s 49(1)(b) of the Coroners Act 1996 (WA) that:
(a) there be no reporting or publication of the name, picture, or any other identifying features of the witness referred to as Operator 116;
(b) there be no reporting or publication of the details about the decision-making criteria, response times, resourcing, guidelines, policies and any other operational aspects of the Western Australia Police Force Tactical Response Group (WAPF TRG) and the WAPF Negotiators Unit; and
(c) There be no reporting or p ublication of the methodologies of the WAPF TRG and the WAPF Negotiators Unit.
Matthew Worthington (Matthew) was in a relationship with Brooke Finnigan (Ms Finnigan), The relationship ended in early October 2020. According to Ms Finnegan, Matthew had been violent and threatening towards her. His behaviours included making threats to shoot her and himself. After the relationship ended, Matthew continued to contact Brooke to try to convince her to resume their relationship.
On Saturday, 21 November 2020, after it became clear that their relationship was over, Matthew went to Brooke’s workplace and threatened her with a handgun before leaving. She notified the police, who began looking for Matthew.
Police Airwing located Matthew’s car and he was tracked back to his house in Hardy Road, Bayswater. He was observed from the air getting out of his car and entering the house. The immediate area was cordoned off by police and officers from the specialist Tactical Response Group (TRG) and Negotiators Unit attended. After waiting for a period of time, a decision was made to enter the house and approach Matthew. Upon entry, Matthew fired shots at the TRG operators, with one of the operators narrowly avoiding being shot. The operators responded by retreating slightly and cordoning off the bedroom Matthew was inside. They did not fire any shots in return.1
A ‘Contain and Negotiate’ strategy was implemented and specialist police negotiators attended the scene and began speaking to Matthew from outside the house. Matthew continued to fire shots intermittently but did not appear to be targeting anyone. The TRG operators eventually withdrew from the house in an effort to de-escalate the situation. Negotiations continued for some time. It was thought they were progressing well and Matthew had become calmer. It was believed he was coming close to surrendering and enabling a peaceful resolution of the incident. However, in the midst of negotiations, at 9.13 am on Sunday, 22 November 2020, a single gunshot was heard
[2023] WACOR 27 coming from the address. The negotiator tried to speak to Matthew, but only laboured breathing could be heard in response.
Matthew was given comfort care until his death on Tuesday, 24 November 2020.
Due to the presence of police officers at the time leading up to Matthew’s death, an inquest was required to be held in order to investigate whether the death was caused or contributed to by any action of a member of the police force, pursuant to s 22(1)(b) of the Coroners Act 1996 (WA). I held the inquest on 18 to 19 April 2023.
At the conclusion of the inquest, I indicated that I would not make any adverse comments in relation to the conduct of the police officers involved in the incident. It was apparent that all efforts had been made by the WA Police Force to achieve a peaceful resolution of the matter and the TRG operators had acted with restraint in dealing with a volatile situation where their own lives were put at risk. Unfortunately, Matthew made the unexpected decision to end his own life and there was no chance of saving him once he took the fateful step of shooting himself at close range.
Matthew was born and raised in Perth. Matthew had been married, but he separated from his wife in about 2015. He had one child from the marriage, who was about 7 years old at the time of Matthew’s death. Matthew was said to be a devoted father to his son. Matthew had been seen at the Narrogin Community Health Clinic around the time of his marriage breakdown and exhibited depressive features and hopelessness.2
Matthew and Ms Finnigan met through Ms Finnigan’s father. Matthew and Ms Finnigan began a relationship in about September 2018. Ms Finnigan also had a young child at the time they commenced their relationship. The couple had known each other for a little while before they started dating and the relationship progressed quickly. They moved in together in October 2018 and lived in a house in Morley. The couple later moved to a rental property in Hardy Road, Bayswater, which is where the later events the subject of this inquest occurred.3
Ms Finnigan’s son lived with them most of the time, other than when spending time with his father. Matthew’s son did not live with him all the time, but he did see him 2 Exhibit 1, Tab 26.
3 Exhibit 1, Tab 10.1.
[2023] WACOR 27 regularly. Ms Finnigan recalled Matthew was really good with both the children and they enjoyed spending time with him.4
While Matthew made an effort to get along well with the children, Matthew had a poor familial relationship with his own parents prior to his death. Matthew had previously lived with his parents on a small farm property in Brookton, where they raised animals and operated a boarding kennel business. On 10 February 2012, Matthew had an altercation with the neighbour on a bordering property. During the altercation, the neighbour struck Matthew with a samurai sword on his head. The blow caused a deep laceration, penetrating into the skull bone and severing two arteries. The neighbour then continued to strike towards Matthew with the sword, causing Matthew to sustain further lacerations to his hand and toe before Matthew and his father were able to disarm the neighbour. The neighbour was later prosecuted. Matthew suffered regular migraines and a serious post-traumatic stress disorder after the assault.5
It appears that these ongoing health issues affected Matthew’s behaviour and relationship with his family. Matthew had told Ms Finnigan about an incident a few years before when Matt had an argument with his father and it escalated to a violent fight. Matthew seriously assaulted his father and from that time his parents and siblings ceased contact with him. A police report was apparently made at one stage in relation to this assault, but it does not appear that Matthew’s father pursed it and the matter was eventually closed due to insufficient evidence.6 It seems that after this time Matthew still had contact with some of his extended family, although it’s not clear how regularly he kept in contact with them.7
Ms Finnigan recalled Matthew suffered from pain related to unsuccessful abdominal surgery and depression at the time she knew him. He took a large number of medications for his pain and mental health issues and was on a disability pension. He slept a lot and appeared to lack motivation to do things, although he did enjoy renovating the house he owned in Bruce Rock.8
It seems clear that Matthew’s life had steadily been deteriorating following the assault against him, and things took a turn for the worse in 2020.
4 Exhibit 1, Tab 10.1.
5 The State of WA v Legge [2014] WASCA 47.
6 Exhibit 1, Tab 25, p. 13.
7 Exhibit 1, Tab 10.1.
8 Exhibit 1, Tab 10.1.
During the Term 3 school holiday break in 2020, Matthew and Ms Finnigan were in Bruce Rock with his son and her son when an argument developed between the two adults. During the argument, Matthew punched three holes in a wall. Ms Finnigan told him that when they got back to Perth she wanted to leave the relationship as she was not going to put up with this kind of behaviour. Ms Finnigan stated that Matthew had previously punched her in the arm and raised his fists at her, but was never violent towards the children.9
When they returned home from Bruce Rock, their relationship continued, but sometime between 3 and 5 October 2020 another incident occurred. At about 4.30 pm on the particular day, Ms Finnigan was standing in the kitchen counting money as she was about to purchase a car. Matthew came home and she noticed he was carrying a plastic Coles bag. As he entered the room, Ms Finnigan was texting someone on her phone. Matthew grabbed the phone off her and said, “Who the fuck are you texting?”10 She told him she was texting a person about buying a car, but he didn’t believe her and put her phone in his pocket. When she asked for the phone back, he refused and pushed her down on the couch.11
Matthew then said, “Why the fuck do you make me do this?”12 She saw him grab a black case from the Coles bag. The black case looked like a gun case. He opened the case and she saw inside a small cardboard box. Matthew opened the box and she saw it contained gold bullets. She could also see a silver gun with a long nozzle.
Ms Finnigan saw Matthew pop open the side of the gun and put three bullets in the barrel. After loading the gun, he then pointed the gun at her and pulled the trigger. No bullet was fired, but he kept the gun pointed at her. Matthew then said, “If you are going to take everything from me, I will take you with me. I will shoot you and shoot myself.”13
He then put the gun to the back of her skull while she was lying face down on the couch. Ms Finnigan tried to get up but Matthew hit her on the back of her upper arm with the gun. It hurt her and left a mark. She was screaming at him to stop, to give her back her phone and to leave the house. She threatened to scream so the neighbours would come to help and then she would tell the police. Matthew eventually gave Ms Finnigan back her phone and she forced him out the front door. He took the gun and its case with him. After he had left, Ms Finnigan said she went outside and vomited. She had never seen Matthew with guns before and had been extremely frightened. Ms Finnigan worked at a hair and beauty salon in Morley. Ms Finnegan used her phone to call an Uber and went to work, where she told two of her work colleagues what had happened. She later told police she did not report the incident to 9 Exhibit 1, Tab 10.1.
10 Exhibit 1, Tab 10.1 [61].
11 Exhibit 1, Tab 10.1.
12 Exhibit 1, Tab 10.1 [67].
13 Exhibit 1, Tab 10.1 [78].
[2023] WACOR 27 police at the time as she was concerned about Matthew getting into trouble and losing access to his son.14
Following this incident, Ms Finnigan and Matthew separated and she went to stay with one of her work friends in Wanneroo before moving back in with her mother and stepfather. In the four weeks following the separation, Matthew continued to contact her and appeared apologetic, sending ‘sorry’ messages trying to win her back. After four weeks, Matthew’s behaviour deteriorated. He admitted he was using methylamphetamine and began acting paranoid. He would check Ms Finnigan’s phone when he saw her and accused her of cheating on him.15
On Friday, 13 November 2020, Ms Finnigan went around to the Hardy Road house.
Matthew was there and appeared very emotional. His father had died three days earlier on 10 November 2020. He told Ms Finnigan he had been a bad partner to her, and he did not want to live anymore. Matthew appeared very depressed and his behaviour scared her. She believed he had been using methylamphetamine again.16
Ms Finnigan arranged for her mother and stepfather to go around to the Hardy Road house on the morning of Saturday, 21 November 2020. It was planned that her mother and stepfather would drive to the house with a trailer to collect some of Ms Finnigan’s property and to return Matthew’s dog, Mischa, at his request.19
Matthew’s father’s funeral was also scheduled to take place on 21 November 2020.
Matthew had apparently told family members he was not up to attending.20
Ms Finnigan’s stepfather, David Reekie (Mr Reekie), was aware that Matthew had assaulted Ms Finnigan and that Matthew had been contacting her and giving her a hard time. Mr Reekie understood Ms Finnigan was fearful of going back to the house, which is why he went with her mother. They understood that Matthew would not be at home.21
They arrived at the Hardy Rd house in Bayswater at about 10.00 am on the Saturday morning. Matthew’s car was parked in the driveway so they parked next to his car and 14 Exhibit 1, Tab 10.1 and 10.2.
15 Exhibit 1, Tab 10.1.
16 Exhibit 1, Tab 10.1.
17 Exhibit 1, Tab 30.1.
18 Exhibit 1, Tab 10.1.
19 Exhibit 1, Tab 10.1.
20 Exhibit 1, Tab 26.
21 Exhibit 1, Tab 11.
[2023] WACOR 27 then knocked on the door. They had a key for the house, but didn’t use it since it appeared Matthew was home. Matthew answered the door and allowed them to collect some of Ms Finnigan’s belongings, including some of her hairdressing equipment.
Matthew stayed in his son’s room while they were there and they did not have much conversation, although Matthew did offer them refreshments. Once they had finished loading the car, they prepared to leave but were stopped by Matthew, who gave them a number of other bags of Ms Finnigan’s belongings. Matthew appeared a little pale but otherwise didn’t appear too stressed. Mr Reekie told Matthew to take care of his dog and himself and then left. After driving away, Mr Reekie and Ms Finnigan’s mother stopped at some shops. When they got back into their car and began driving again, they saw Matthew in his car pulling out onto Guildford Road. He disappeared from view and they did not see him again. While they were still driving home, Ms Finnigan rang her mother and told her that Matthew had been to her work.22
Matthew and Ms Finnigan had been exchanging text messages earlier that day about the arrangements for collecting her belongings and dropping off his dog. Matthew had said he was feeling alone and one day she would know how it feels. At about 10.40 am, Matthew sent Ms Finnigan a text message saying, “Last chance. Will you please give us another try?’23 Ms Finnigan replied, “I’m at work is that a threat?”24
Matthew arrived at Ms Finnigan’s workplace in Morley shortly after, at about 11.15 am. She had not been expecting to see him. There were no customers and the only other person in the salon was Ms Finnigan’s colleague. Matthew walked into the salon as Ms Finnigan returned from a cigarette break. From his appearance she thought he was affected by methylamphetamine. He said to Ms Finnigan, “You’re not busy, do you have time to fit me in for a haircut, before I go to my Dad’s funeral?”25 Ms Finnigan looked at the appointment book and knew she could fit him in. She didn’t want to make him angry, so she said she could fit him in if they did it quickly. Matthew sat down in the salon chair and she cut his hair. While she was cutting his hair, they had general conversation about his Dad’s funeral and her collecting her belongings.26
After she had finished cutting his hair, Ms Finnigan walked over to the front counter so that Matthew would have to get up and follow her. She was hoping he would leave.
He asked her how much he owed her and she said not to worry about it. Ms Finnigan then walked out the front of the salon, in the hope he would follow her and leave. She left her female colleague inside. Matthew and Ms Finnigan had a brief conversation outside the salon. She told him, “You can’t just rock up to my work place.”27
23 Exhibit 1, Tab 10.1 [128].
24 Exhibit 1, Tab 10.1 [129].
25 Exhibit 1, Tab 10.2 [14].
26 Exhibit 1, Tab 10.1 and 10.2.
27 Exhibit 1, Tab 10.2 [22].
28 Exhibit 1, Tab 10.2 [23].
Ms Finnigan recognised it as the gun he had previously threatened her with, and she had also seen it in the photo he had sent her previously. Ms Finnigan told him to put it away and he said, “I don’t care you are better to be my friend than my enemy.”30 Ms Finnigan started crying and Matthew told her not to make a scene or he would do something. He said words to the effect he wanted Ms Finnigan to care about him and his son and was sick of ‘playing nice’. He basically threatened her if she did not get back with him, telling her she was safer with him than not. In the end, Ms Finnigan promised Matthew she would go over to his house and see him after work. He made her promise to come over, which she did. He then walked off.31
Ms Finnigan’s call to police was recorded at 12.08 pm. She confirmed with the police that he had left at 12.11 pm. A CAD job was immediately created. Police Airwing had located Matthew’s car by 12.25 pm and they maintained observations of him as he drove to his home in Hardy Road, Bayswater. He was observed getting out of his car and entering the house, carrying a box. The immediate area was cordoned off by police and TRG were advised. Officers from the Regional Operations Group (ROG) knocked on the front door of the house, but no one answered.34
Acting Inspector Philip Bonner, the Duty Patrol Commander, at State Operations Command Centre, was advised of a possible police siege developing at the Bayswater address around 12.40 pm and he took a quick briefing then went to the scene and assumed command of the situation just after 1.00 pm. The aim of the operation was to arrest Matthew for suspected firearm offences as safely as possible for all involved.
A/Inspector Bonner explained that there were many different officers from different units involved, many with specialist training. They all provided information and options through the chain to him, but it was ultimately his role as commander to make the final decision as to what steps would be taken.35 29 Exhibit 1, Tab 10.2 [30].
30 Exhibit 1, Tab 10.2 [22].
31 Exhibit 1, Tab 10.2 [22].
32 Exhibit 1, Tab 10.1 [173] and Tab 26.
33 Exhibit 1, Tab 10.1.
34 Exhibit 1, Tab 2.1 and Tab 26.
35 T 10 - 15; Exhibit 1, Tab 17.
They discussed and agreed upon a ‘Surrender Plan’, which covered how the negotiator should arrange for Matthew to exit the house if he agreed to surrender, which was approved by A/Inspector Bonner. They then tried to text and call Matthew on his mobile, and also made two calls via the public address system, but he did not respond.37
A/Inspector Bonner requested a triangulation of Matthew’s phone, which confirmed he was still at the Bayswater house.38
The area around 122 Hardy Road had been cordoned off to mitigate risk to neighbours, community members and attending emergency services staff. The neighbours were encouraged to vacate leave their homes and members of the public were discouraged from entering the area. This obviously put some time pressure on police to try to resolve the situation, although they did not let it unduly influence their decisionmaking, with the primary aim to resolve the situation safely rather than quickly.39
As all attempts to make contact with Matthew had been unsuccessful, and it seemed clear he was in the house but was not responding to the police overtures, A/Inspector Bonner began to have concerns for his welfare. A decision was made at about 3.00 pm to breach the door and enter the house to confirm that Matthew was actually inside and that he was not injured and requiring assistance.40
Initially, there was an attempt to simply get some vision within the premises electronically through a device, and then at 3.25 pm approval was given for officers to enter. On police entry, Matthew fired two shots at TRG operators from a bedroom within the house. The TRG operators remained in the house and retreated to safe positions, while waiting further instructions. They did not at any stage fire in response, despite the fact at least one of the shots narrowly missed an operator.41 At this stage, Matthew was contained within the bedroom and the police were 99 per cent certain he was in there by himself.42
A/Inspector Bonner had arranged for Ms Finnigan to come to the scene, to see if she could help the police negotiators to communicate with Matthew. She arrived at Hardy Road sometime around 4.00 pm and spoke with the police negotiators. They asked her 36 A/Det Sgt Morrell at the time of the inquest – T 29.
37 T 17; Exhibit 1, Tab 24.
38 Exhibit 1, Tab 17.
39 T 20; Exhibit 1, Tab 24.
40 Exhibit 1, Tab 17.
42 T 22 – 23; Exhibit 1, Tab 24.
[2023] WACOR 27 if she could attempt to contact Matthew. Ms Finnigan called him, but he did not answer. She stayed at the scene until around 4.30 pm, at which time she was told by police she could leave.43
The WA Police negotiators form part of the WA Police TRG Negotiators Unit. All of the negotiators nominate themselves for the role through an expression of interest and go through a stringent selection process, including psychological assessment. The top 10 successful applicants then undergo an initial two week period of training, and those who successfully complete the course and become negotiators must then complete a year of training sessions and once they are deemed competent, they are put on the roster, but continue to participate in ongoing regular training sessions thereafter.45 Other than the Coordinator and the Training Officer, the other negotiators are all parttime police negotiators, with a total strength of 25 trained and operational negotiators at the time of this incident.46 This remains roughly the same today, with approximately 26 negotiators expected to be available to perform on-call duties by the end of 2023.47
Det S/C Morrell completed the WA Police Negotiators Course in August 2019 and was one of the latest members to come on board the negotiators team. Due to the parttime nature of the role, she had been rostered on call intermittently since that time, performing her ordinary duties at her substantive work location and having the on-call phone when off duty. Det S/C Morrell had been involved in other negotiations, where there was a successful outcome, prior to this day.48
Det S/C Morrell explained that the negotiator is not involved in the police investigation, but sits separate from it so that they can have an open dialogue with the person at risk and engage with them in an attempt to defuse the situation. They aim to build rapport and try to understand the reason why the person is in the crisis situation, de-escalate their fears and hopefully resolve the crisis with a peaceful resolution. They do not make false promises about the police investigation and whether the person might face charges, but their focus is on the state of mind of the person at risk and 43 Exhibit 1, Tab 10.1.
44 Exhibit 1, Tab 14.3, Tab 17 and Tab 24.
47 Letter to CA from SSO dated 20 April 2023 regarding resourcing of the Negotiators Unit.
48 T 126; Exhibit 1, Tab 14.1.
[2023] WACOR 27 trying to help them to remain calm and to cooperate with the police and keep themselves safe.49
Det S/C Morrell was the Primary On call Negotiator that day, so she had received the initial call and contacted the Secondary On call Negotiator, Det Sgt Smith, and the Negotiators Unit Coordinator, Sergeant Craig Reynolds, to ensure that everyone was aware of the situation and resources would be available if the matter was ongoing. At the scene, she was briefed and given as much information as possible about Matthew and the situation he was in, including his relationship breakdown with Ms Finnigan, the fact his father’s funeral was being held that day and the circumstances of the incident at the salon. There had been no meaningful contact between the police and Matthew before Det S/C Morrell got to the scene, and it had taken some time for communication to begin between Matthew and Det S/C Morrell. She believed the delivery of the Coke was a turning point, and from then he began to engage with the police a little more, initially sending a ‘thumbs up’ emoji in relation to the Coke and then continuing from there.50
When Det S/C Morrell and Matthew did first start to communicate, she recalled “his anxieties were about what would happen to him when he came out, because he had already shot at the officers. He was under the belief that they would then retaliate by shooting back.”51 He was also concerned about spending a period of time in jail for shooting at police.52 Det S/C Morrell tried to reassure him that if he left his firearm inside, police would not shoot him if he came outside and surrendered. Det S/C Morrell also recalled she talked to him about his son and the fact he had missed his Dad’s funeral, as ways to establish rapport and get a conversation flowing.53 Det S/C Morrell could not recall Matthew mentioning any thoughts of self-harm during her conversations with him, although she had noted the text he had sent to Ms Finnigan earlier, “You’ve killed me,” and made a note that he had threatened to kill himself and that Ms Finnigan believed he had become more and more depressed and wouldn’t go down without a fight.54
Det S/C Morrell and Matthew communicated by text message initially, and later by phone.55 Matthew’s phone had begun going flat at around 5.30 pm and he texted Det S/C Morrell to tell her that he couldn’t recharge it as the power was off. He wanted the power turned on but this was not able to be done for some time, despite attempts by police. Instead, he was initially given a different two-way communication device around 6.00 pm, and then another power battery was provided for his phone, which he confirmed he had received.56
A/Inspector Bonner was replaced as Forward Commander by Inspector Darren Wynne at around 6.00 pm. The plan to contain and negotiate continued after the handover to the new Forward Commander, as there was no immediate threat to members of the 49 T 31 – 32; Exhibit 1, Tab 14.1.
50 T 34, 38, 40; Exhibit 1, Tab 14.3.
52 Exhibit 1, Tab 14.1.
54 T 39 – 40; Exhibit 1, Tab 14.3.
56 T 38 – 39, 57; Exhibit 1, Tab 14.2 and Tab 17 and Tab 24.
[2023] WACOR 27 public and it appeared the best strategy to ensure that no one would be harmed.
Inspector Wynne gave evidence he understood that because Matthew had fired at the police, he thought they were going to shoot him, and this was a big hurdle to overcome in terms of the negotiation process. Therefore, it was an exercise in patience to try to gain Matthew’s trust over time. The plan did not change until the end, when it seemed very likely that Matthew had harmed himself. This was after Inspector Wynne had handed over to another Forward Commander, Inspector Darren Taylor. Just before Inspector Wynne had handed over to Inspector Taylor, Matthew had given an indication he was willing to come out, but just needed more time, so at that stage it had appeared things were progressing well and Inspector Wynne said he had felt buoyed by that information. Unfortunately, Matthew appears to have changed his mind but did not communicate that to the police.57
Det S/C Morrell was also eventually replaced by her then supervisor, Sergeant Craig Reynolds. Sergeant Reynolds had recently retired from the WAPF at the time of the inquest, but prior to his retirement he had been a negotiator for 29 years and in the role of the Negotiation Unit Coordinator at the TRG for just over 8 years. It is fair to say he was the most experienced negotiator in the WAPF at the time he took over from Det S/C Morrell and he is classed as a subject matter expert in that role.58 Sgt Reynolds began negotiations with Matthew and continued with Det S/C Morrell’s efforts to try to bring the matter to a peaceful resolution. Sgt Reynolds gave evidence that almost all of the incidents in WA where negotiators become involved are resolved without anyone being harmed, so that was his expectation on this day.59
Sgt Reynolds had arrived at the scene some time before the handover so that he could gain an appreciation of the conversation and how it was tracking by listening in and also talking to the second negotiator. Sgt Reynolds had formed the view that Det S/C Morrell “was doing a marvellous job.”60 Matthew had appeared very compliant and the threat assessment at that time appeared to Sgt Reynolds to be low. He also formed the impression that Matthew was likely to come out very shortly. However, Det S/C Morrell required a comfort break and given the length of time that had passed, it was appropriate to swap her out as part of a change of shift of negotiators.61
Sgt Reynolds met Det S/C Morrell in the TRG BearCat, an armoured vehicle that allows the negotiator to be located safely near to the person at risk, then they conducted a quick handover before Det S/C Morrell introduced Matthew to Sgt Reynolds and explained that Sgt Reynolds would be taking over and Matthew was in good hands.
Det S/C Morrell then returned to the command post, but she continued to listen in for a period to ensure that nothing was raised that required her input or further explanation.
Det S/C Morrell gave evidence that for the entire time she had been in negotiation with Matthew, she had been trying to get him to engage with them. At the time she handed over to Sgt Reynolds, she believed Matthew had only just been starting to engage a little bit, so she did not believe the transition greatly disadvantaged the negotiations.
57 T 53 – 55, 58 – 59, 61 – 62, 67; Exhibit 1, Tab 17 and Tab 18 and Tab 19.
59 T 124 – 125, 128; Exhibit 1, Tab 15.
[2023] WACOR 27 Matthew was indicating at that time he was confused and still scared about being shot, despite the reassurances given.62
Ms Finnigan advised the police sometime before 5.18 pm that she had received texts from Matthew with information on how he wanted to distribute his assets.64 Hours after Ms Finnigan left, she received a text message from Matthew at about 8.30 pm saying, “Get Mischa,” which she understood to be a message telling her to get their dog, who had been dropped back to Hardy Rd that morning by her parents.65 Mischa apparently ran away during the commotion when the TRG first entered the house. She was eventually found and secured. A note was made that she was safe in the morning, so that the information could be provided to Matthew as he had expressed considerable concern about his dog throughout the night.66
Ms Finnigan spoke to Matthew a number of times later that evening. She had been drinking and became intoxicated. She last spoke to him at about 11.30 pm, at which time Matthew sounded really angry and told Ms Finnigan it was her fault his son was going to grow up without a father. She became angry in response and they had a terse conversation. Ms Finnigan contacted the police negotiator at about 6.00 am on Sunday, 22 November 2020 and told them that she was going to block Matthew from her phone, which she then did. She had no further communication with Matthew from that time.67
At 9.09 pm, Matthew’s aunt, Christine Worthington, rang police to offer her assistance in any way she could. She advised police that Matthew had called his grandmother at 8.40 pm and told her he had shot at police. After the inquest, his aunt Pauline Gerrans advised that Matthew had also told his grandmother that he was going to shoot himself, although this is not recorded in the police note. Matthew’s grandmother said the rosary with Matthew and believed she had talked him out of harming himself. Some of Matthew’s extended family were still together at Pauline’s house, after the wake, and Matthew’s grandmother rang to inform them of the call. His Aunt Christine had then made the call to police, providing Pauline’s number, in case there was anything they could do to help. They did not hear back from police until after Matthew’s death.
Matthew’s brother also contacted police sometime later, indicating they were estranged but he was willing to help in any way he could.68
64 Exhibit 1, Tab 17 [53].
65 Exhibit 1, Tab 10.1.
67 Exhibit 1, Tab 10.1.
68 Exhibit 1, Tab 26.
[2023] WACOR 27 nor that the family had called in to police to offer help if required. The police had utilised Ms Finnigan at an early stage, but not later.
Sgt Reynolds, recalled that in the hours that the negotiators had been speaking to Matthew, they had explained to him that the police were never going to leave and he knew he was in trouble as he had fired at police, so there were going to be ramifications for that conduct. However, he continued to try to reassure Matthew that if he came out unarmed and surrendered, he would not be shot and, while he would be arrested, he would then be taken to a hospital for a mental health assessment. Sgt Reynolds said Matthew mentioned he felt very anxious, although he appeared calm, and he had been assisted to do a breathing exercise to try to help him focus. Sgt Reynolds was not aware at that time that Matthew had amphetamine in his system, and he did not give the appearance of being affected by drugs. The police had managed to get the power on, so Sgt Reynolds was able to speak to Matthew on the phone, and he had thought that their communication was progressing reasonably well. Matthew was still expressing concern about being shot by police, and did not mention any thoughts of self-harm, so what happened next was entirely unexpected.70
Inspector Taylor, who was the Forward Commander at the time, had been briefed around 7.30 am by the TRG Tactical Commander about the communication between Matthew and the negotiator, so he had been feeling confident that they were moving in the right direction. At 8.22 am, Operator 116, who was the TRG Tactical Commander at that time, discussed some further action plans and resolution strategies with Inspector Taylor. These were raised given the incident had become prolonged, so it was necessary to consider whether an alternative option to the ‘contain and negotiate’ strategy might become necessary. Inspector Taylor indicated he would consider the plans and discuss with the Police Commander.71
Then, from out of the blue,72 Inspector Taylor was advised by Operator 116 at around 9.13 am that they had heard a single shot from inside the premises. Two minutes later, he was advised that the TRG negotiator, Sgt Reynolds, who had been on the phone to Matthew at the time of the shot, could hear laboured breathing on the phone, as well as other sources hearing laboured breathing from within the house. The police were
71 T 67 – 69, 78, 83; Exhibit 1, Tab 16 and Tab 19.
[2023] WACOR 27 immediately concerned that Matthew had fired his gun and injured himself. It was necessary to consider that this could be a ploy to draw officers in to harm’s way, so safety concerns had to be weighed up before any action was taken, but the need to make sure Matthew was alive and not requiring medical attention was pressing.73
It appeared the injury had been self-inflicted with a firearm.75
Matthew was found on his back in the front bedroom, below the bedroom window, with a wound to his head and a firearm resting in one of his hands. The firearm, a revolver, was removed by one of the TRG operators and placed on the front porch below the bedroom window, for safety reasons. It was later photographed and seized by officers from the Forensic Firearms Unit.76
A waiting ambulance was immediately dispatched to the house, and it was there within two minutes. When the SJA paramedic entered the house, TRG operators were already providing first aid to Matthew, who was still alive but breathing noisily and bleeding heavily from the right side of his head.77 The TRG operators assisted the SJA officers to extract Matthew from the house and Matthew was then taken by ambulance to Royal Perth Hospital (RPH) for emergency medical treatment.78
Matthew was assessed by doctors at RPH and determined to have a severe penetrating brain injury as a result of a gunshot wound. Two doctors certified brain death on 24 November 2020 and Matthew’s death was formally certified at 2.20 pm that day by an ICU Consultant.79
Matthew’s aunt, Ms Pauline Gerrans, was identified as his next of kin and was notified by police of his death. She later assisted to identify his body for police.80 Ms Finnigan was also notified by police of Matthew’s death.
73 T 67 – 69; Exhibit 1, Tab 19 and Tab 21.
74 T 67 – 69; Exhibit 1, Tab 19 and Tab 21.
75 T 85; Exhibit 1, Tab 19.
76 Exhibit 1, Tab 21.
77 Exhibit 1, Tab 25, pp. 14 – 15.
78 Exhibit 1, Tab 16.
79 Exhibit 1, Tab 5 and Tab 6.
80 Exhibit 1, Tab 2.1 and Tab 4.1.
Forensic Pathologist Dr Moss conducted a post mortem examination on the body of Matthew on 26 November 2020. The examination was attended by two detectives from the Homicide Squad and two forensic officers. The post mortem examination showed gunshot injury to the head with an entrance wound to the right side and exit on the left side. There was significant underlying brain injury and multiple skull fractures. There were early blood clots to the lungs. Neuropathology examination showed traumatic brain injury.81
Toxicology analysis showed the presence of methylamphetamine and amphetamine in the blood. This was consistent with Ms Finnigan’s understanding that Matthew had been taking methylamphetamine since their break-up and was affected by it when he came to the salon immediately prior to the siege. It is well known that methylamphetamine can affect the mental state of users and make them feel paranoid, as well as causing them to behave in an aggressive and unpredictable manner.
Some prescription medications were also present in the ante-mortem hospital samples, including the antidepressant venlafaxine, the benzodiazepine diazepam and the opioid tramadol.82 Additional medications were detected in the post mortem samples, that were likely to be related to Matthew’s medical treatment at Royal Perth Hospital. They did not contribute to the cause of death.83
Dr Moss formed the opinion the cause of death was gunshot injury to the head.84 I accept and adopt Dr Moss’ opinion as to the cause of death.
Due to the presence of police at Matthew’s house at the time he was fatally injured, the case was deemed a critical incident involving police. Therefore, even before Matthew’s death, an investigation commenced into the actions of the police. The case was allocated to Homicide Squad to manage the investigation in accordance with their charter of responsibility for critical incidents involving police. Detective Sergeant Clinton Bragg was the Investigating Officer and Detective Senior Sergeant Arthur Neubronner was the Senior Investigating Officer. It was given the Operation name of ‘Melfi’. The initial purpose of the investigation was to establish whether there was any criminality, and then following Matthew’s death and a conclusion that no charges should be laid, it was investigated by the Homicide Squad detectives on behalf of the State Coroner.85
A walkthrough of the scene had been conducted and recorded by TRG operators at 9.44 am, immediately after Matthew had been taken to hospital. Forensic officers, 81 Exhibit 1, Tab 7 and 9.
82 Exhibit 1, Tab 8.
83 Exhibit 1, Tab 8.
84 Exhibit 1, Tab 7.
85 T 94; Exhibit 1, Tab 2.1 and Tab 2.2.
[2023] WACOR 27 including officers from the Forensic Firearm Unit and a Bloodstain Pattern Analyst, then attended the house to examine the scene that day and the following day.86
In total, the evidence supported the conclusion 11 shots had been fired from within the premises. It is clear from the diagram below that other than the single shot against the wall that related to Matthew’s injury, the others were fired from the bedroom out towards the door and hallway, consistent with Matthew firing from the bedroom at the TRG operators and TRG devices.88 Exhibit “1” tab 21 from the Firearms Report depicts the bedroom showing the location and the number of shots fired.
86 Exhibit 1, Tab 21 and Tab 22.
87 Exhibit 1, Tab 22.
88 Exhibit 1, Tab 21.
The examinations by Senior Constable Milonas found evidence that suggested that the bullet that fatally injured Matthew came from the revolver found near him, although direct comparison of the fired bullet found on the floor of the bedroom was inconclusive.89
The two firearms found at Matthew’s home were unlicensed and had both had their serial numbers removed. They were both eventually traced back to firearms that were stolen in a burglary. It was unclear how they had come into Matthew’s possession, although there had been a suggestion in the evidence that he had purchased them from someone. Police searched Matthew’s other properties and found more firearms, so it is clear he was someone who had an interest in guns that went beyond the incident leading up to his death.90
The examinations conducted by Sgt Blaver, the blood spatter analyst, led to the conclusion Matthew was seated on the floor in the southern corner of the front bedroom at the time of the infliction of the gunshot injury to the head.91
Both of these officers explained their findings to Det Sgt Bragg and he considered this information in conjunction with the medical evidence from Matthew’s hospital treatment and the post mortem findings. The evidence was consistent with Matthew having fired the fatal shot at close range from the Ruger pistol revolver found in his lap. Given the weapon he used, and the fact he fired at his head at close range, his actions supported the conclusion he had an intention to end his life. This was consistent with other information provided about messages and statements Matthew had made during the night and the fact he was experiencing a number of personal stressors relating to his relationship breakdown and father’s death, although he never made a direct statement that he intended to harm himself.92
As part of his investigation, Det Sgt Bragg reviewed the transcript of the negotiations and he saw nothing there to suggest that Matthew was imminently going to shoot himself. Deg Sgt Bragg commented that much of Matthew’s concerns had been around his fear that the police would shoot him if he came out, so it was unforeseen that he would actually shoot himself.93
I accept the conclusions of Det Sgt Bragg and I find the manner of death was by way of suicide.
91 Exhibit 1, Tab 21 and Tab 22.
[2023] WACOR 27 guidelines.94 Detective Sergeant Michael Butcher was the IAU investigator tasked with leading this investigation.
This included the conduct of the negotiators, who fall within the TRG portfolio although their actions are independent of the work of the other TRG officers during an incident. Inspector Kazandzis was not involved in the incident, so it was considered he was well situated to provide an independent review as a subject matter expert.95
Inspector Kazandzis observed that the response of the TRG operators not to return fire when they were fired upon by Matthew in the early stages, was very professional. They showed restraint by simply disengaging and taking cover. They also then ultimately disengaged from the premises, in order to allow the negotiations their best chance of success. Inspector Kazandzis expressed the view the de-escalation was commendable, and it appeared to have the desired effect, as from that point on the negotiations appeared to progress and there was potential for a surrender to occur. Inspector Kazandzis noted that over the ensuing hours, the TRG operators did consider a wide variety of options to resolve the incident, but the safety and welfare of Matthew and the TRG operators indicated the strategy of negotiating a surrender was the safest course, given there was a significant risk that any other action might make Matthew feel he was compelled to respond with firearms, as he had done earlier.96 Inspector Kazandzis gave evidence that, based upon his review, he did not identify anything that ought to have been done differently, given what was known at the time.
Inspector Kazandzis gave evidence the TRG are “always seeking continuous improvement,”97 which occurs through the debrief process that occurs after every incident in which the TRG is involved. The focus is on identifying ways to innovate and look at equipment that is going to allow the operators to do their job better, be safer in the role and, by extension, improve the safety of the persons at risk and the community.98 There were perhaps some capability gaps identified in this incident in terms of being able to get access to the room in which Matthew had taken refuge and to get him to come out. Inspector Kazandzis gave evidence there is now some new equipment that might assist in a similar situation in a future matter, but he emphasised that irrespective of what equipment is available, the “golden thread” that runs through all decisions is the planning around how to “achieve a safe resolution of the incident for the person at risk, the tactical operators and community members.”99 Therefore, even when it is available, some equipment will only be used in a rare cases, or the “one percenters”100 as Inspector Kazandzis called them. However, as previously mentioned, “contain and negotiate” is the preferred response strategy for the resolution of high
95 Exhibit 1, Tab 24 and Tab 25.
[2023] WACOR 27 risk situations when it is considered achievable, as this has the lowest risk of harm being caused to any person.101
Det Sgt Butcher provided a report to the Court indicating he had considered the evidence obtained in the Homicide Squad investigation and TRG Review, as well as some footage from PolAir and other video footage taken at the scene and from bodyworn cameras that some officers were wearing. Another IAU investigator, Detective Senior Sergeant Van Der Schoor, was on call at the relevant time and had attended the incident scene on the day, after Matthew was taken to hospital, and met with other officers briefly, and relevant information was passed on to Det Sgt Butcher for his investigation. Det Sgt Butcher was able to listen to the recordings of the negotiations between Matthew and Det S/C Morrell and Sgt Reynolds and he noted they both continually encouraged Matthew to come out of the house and surrender, but he continued to protest and provide different reasons and excuses not to leave, until the single gunshot is heard six hours and 22 minutes after he had begun speaking to Sgt Reynolds, and more than 18 hours after the negotiations first commenced.102
Det Sgt Butcher did not identify any areas where police failed to comply with any policies or procedures or code of conduct. He also concluded the officers involved did nothing to contribute to Matthew’s death, in the sense of provoking him or forcing him to take the action that he did.103
The general evidence from the police officers who gave evidence at the inquest was that siege type incidents like this involving a firearm are rare in Western Australia, and more often than not they result in the person surrendering to police.104 The evidence of the experienced TRG operators was to the effect that they had all felt the negotiations were progressing well, and they had expected the same resolution in this case. They were all surprised when they heard the gunshot in the morning, as Matthew had been giving the impression he was preparing to come out, and had not given any warning that he was contemplating harming himself at that time.
In recent years, following previous recommendations from an inquest, the way the Negotiation Unit is resourced has allowed two negotiators to attend any incident, which has given them both a better ability to respond and to manage a situation, as well as to provide support to each other.105 Sgt Reynolds gave evidence that demonstrates how the Negotiators Unit is generally a very successful tool in the TRG arsenal for resolving incidents safely. He explained that in the year that Matthew died, there were 165 cases involving negotiators, with 74 of them barricaded and threatened suicides, and Matthew’s death was the only fatality in those cases. In 2021, they were involved in 147 cases with no fatalities, and in 2022, they were involved in 190 cases, that led to only one suicide in police presence. The two deaths are obviously a matter
102 Exhibit 1, Tab 25.
103 Exhibit 1. Tab 25.
[2023] WACOR 27 of great regret to the negotiators involved, but the large numbers of successful resolutions are also important to acknowledge.
They had been discussing the fact that it was daylight, which was a good time for him to come out as everything was in plain view and there could be no misunderstanding.
Sgt Reynolds had been talking to Matthew about the arrangements that would be made for his surrender when he heard a muffled sound, that he did not initially recognise as a gunshot, and then he received word back from other TRG operators that they believed a gun had been fired and it then became apparent that Matthew’s breathing was laboured and it was likely he had injured himself. Sgt Reynolds could not recall Matthew saying anything to hint at what he was about to do, before it happened.106
Sgt Reynolds described Matthew’s death as a tragedy, and it is clear he was deeply impacted by it. He had been unable to listen to the tape of the negotiations again after that date, but had still reflected on the conversations many times. Sgt Reynolds gave evidence at the inquest that he had been shocked at the time, and still felt that Matthew’s fatal act was completely unexpected as there was no obvious trigger for his action. He said frankly at the inquest that as the most experienced negotiator in the unit at that time, he would have put money on the fact that Matthew was coming out, and his second negotiator at the time was the second most experienced negotiator, and he also had reached the same conclusion.107
Evidence was given by Sgt Reynolds and Det S/C Morrell that there is good psychological support for the negotiators. Within the negotiators team they speak openly and often, and external psychological support is also available. The monthly training is continually focussed on learning from previous cases and negotiators often debrief on each other’s cases, to see what worked and what didn’t, to assist them all to continually build their repertoire of negotiating skills to utilise, where appropriate, in different incidents.108
Not long after this incident, negotiators began wearing body worn cameras, as part of the rollout of bodyworn cameras across the WAPF. It had already been planned, but Matthew’s death was a catalyst for it to be brought in to the unit within weeks, and since then new versions of the cameras have been introduced that give better capability for the negotiators and enable the Forward Commander to understand what is happening from the negotiator’s perspective and gives them informed intelligence of what is happening at the front, away from the command post. It is also a useful training tool for other negotiators.109
Inspector Taylor gave evidence that post this incident, the WAPF increased its training of police forward commanders (Inspectors) to ensure they have a better appreciation of TRG capabilities, decision making authorities and the way the planning approvals
[2023] WACOR 27 need to be signed, prior to being involved in an incident. This is designed to streamline the decision-making, and is not to suggest that there was insufficient knowledge or delays in this matter that may have prevented the outcome.110
I have noted above that there have been some significant changes in the resourcing of the Negotiators Unit following recommendations I made in a previous inquest. In that inquest, the death arose in very similar circumstances. Obviously, those changes were not able to prevent this further death, but I also note the evidence of Sgt Reynolds to the effect that the additional resourcing has vastly improved the way the negotiators operate at a scene, including their ability to liaise with family members and to support each other while performing a very challenging task, and the number of fatalities in cases involving negotiators is statistically very low. It is very pleasing to see how the WAPF embraced the recommendations and to see how they have achieved the desired outcomes.
With those comments in mind, I note that Sgt Reynolds, who has himself now retired, suggested that the unit is still missing a third permanent member, who can backfill for the other two permanent members when they take their leave and go to national training. Currently, the lack of a third officer means there is only one permanent officer in the unit for at least four months a year. I understand a request for a third permanent staff member in the unit is supported by management, but has not been able to be achieved thus far. Sgt Reynolds commented that the two permanent members in the unit have a “huge responsibility for the welfare of the people”111 in the unit, because they invest so much time in training them on an ongoing basis and this is necessary to keep them to the level required to be effective.
Further, the current Coordinator of the unit has put up a proposal for a negotiator response vehicle, which has a soundproof cell for the negotiating team so they can work independently and quietly from the other TRG officers. The vehicle has been funded and is currently being built, with the hope it will be rolled out in the near future.112
I continue to be impressed by the passion of the individuals involved in the Negotiator Unit and the results that they are able to achieve. A death like Matthew’s is the sad exception to the usual cases where negotiators become involved, and it is clear that these isolated deaths are felt keenly by not only the particular negotiators involved, but also the other members of the unit. Anything that can be done to assist them in their work should be a priority. I am cognisant of the fact the WAPF has limited resources that have to be stretched in many different directions, but in my view the Negotiators Unit is a proven tool for assisting the police and the community to de-escalate highrisk incidents. Matthew’s death was unable to be prevented, and it is not entirely clear why the negotiations failed, but I have no doubt that all of the negotiators will continue to try to learn from his death to prevent further deaths in the future.
[2023] WACOR 27 Recommendation I recommend the WAPF give priority to funding a third, additional, permanent member of the Negotiators Unit to ensure continuity of staff and consistency of training and support for the negotiators, so that they can continue to perform their important work to the best of their ability.
Matthew was going through a personal crisis in November 2020 and found it difficult to cope. Rather than accepting the end of his relationship, he took the wrong path and made threats towards his former partner, Ms Finnigan. She quite rightly became fearful for her safety and reported his disturbing behaviour to the police. Due to the involvement of a firearm, the matter quickly escalated and Matthew was soon surrounded by police in his home. He made it clear he was prepared to fire at police if they tried to arrest him, so a long siege then began while negotiators tried to convince Matthew to see reason and surrender himself to the police. There were always going to be consequences for his behaviour, but Matthew was encouraged to accept those consequences with the understanding that he would not be harmed if he came out unarmed and he would be given an opportunity to be psychiatrically assessed and given the help he needed.
Sadly, while it appeared the negotiators had been making progress and there was a realistic hope that he was about to surrender, it appears Matthew changed his mind and decided that he would take the only other option he saw available to him. Without warning, Matthew shot himself with his revolver, causing an injury that led to his death despite urgent medical treatment.
I am satisfied that at the time he shot himself, Matthew knew the injury would be fatal and he had consciously made that choice to end his life. While it could be said the police presence contributed to his decision to take his life, I do not make any adverse comment against the police for that fact. The police officers involved could not simply have walked away and left Matthew there, given he was known to have a firearm and had made threats to use it against other people. They had taken the less confrontational option of containing Matthew and trying to negotiate with him, which in most cases is successful, but tragically in this case did not have the outcome that was expected.
People are often unpredictable, particularly when under stress and affected by amphetamines, and I accept there was nothing to indicate to the police that Matthew had made that fateful decision until it was too late to do anything to try to save him.
S H Linton Deputy State Coroner 18 July 2023
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