Deceased
Michael John Bird
Demographics
22y, male
Coroner
Deputy State Coroner Linton
Date of death
2022-03-17
Finding date
2024-05-08
Cause of death
Multiple injuries from fall from 21st floor balcony
AI-generated summary
Michael Bird, 22, died by suicide on 17 March 2022, jumping from the 21st floor of his new workplace on his first day as building manager. He had been experiencing auditory hallucinations and paranoid delusions about police surveillance for several months, likely due to an undiagnosed psychiatric condition. He disclosed these symptoms to a psychologist on 15 March but not to his GPs. His GP on 16 March was unaware of the psychosis and, without this critical information, appropriately assessed him as low-risk for psychiatric emergencies. The coroner found police negotiators did everything possible during a two-hour negotiation and did not cause or contribute to his death. Key clinical lessons: psychosis can present subtly and patients may selectively disclose symptoms; coordination between GPs and psychologists is essential; and even without disclosure, patients presenting with insomnia and anxiety should be asked directly about hallucinations and delusions.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
[2024] WACOR 22 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON, DEPUTY STATE CORONER HEARD : 9 APRIL 2024 DELIVERED : 8 MAY 2024 FILE NO/S : CORC 700 of 2022
DECEASED : BIRD, MICHAEL JOHN Catchwords: Nil Legislation: Nil Counsel Appearing: Mr W Stops assisted the Coroner.
Ms R Hartley (SSO) appeared on behalf of the WA Police Force.
Mr E Panetta (MDA National) appeared for Dr Reddy.
Case(s) referred to in decision(s): Nil
[2024] WACOR 22 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Deputy State Coroner, having investigated the death of Michael John BIRD with an inquest held at the Perth Coroner’s Court, Court 85, CLC Building, 501 Hay Street, Perth on 9 April 2024, find that the identity of the deceased person was Michael John BIRD and that death occurred on 17 March 2022 at 673 Murray Street, West Perth, from multiple injuries in the following circumstances:
TABLE OF CONTENTS SUPPRESSION ORDER Suppression and restriction of publication of Western Australia Police Force Negotiator Unit methodologies and Tactical Response Group deployment guidelines.
Order made by Deputy State Coroner SH Linton (09.04.2024)
However, while still in negotiations, Michael drank some water then suddenly turned around and jumped off the balcony in the presence of the police negotiators. Michael suffered multiple injuries in the fall that were incompatible with life.
Michael is survived by his parents, John and Judith, and his brother Stephen. They were contacted by police officers during the negotiation process and provided background information to the police. Michael’s family advised that Michael’s behaviour was completely out of character, although it was noted he had recently come out of COVID19 isolation and it was unclear if this had adversely affected his mental state.
A coroner must hold an inquest if a reportable death appears to be caused, or contributed to, by any action of a member of the Police Force. Given Michael died in the presence of police, I was required to hold an inquest and give consideration to the actions of the police involved with Michael immediately prior to his death, in order to determine whether they could be said to have caused or contributed to his death.1
I held an inquest on 9 April 2024. During the inquest, I gave specific consideration to the conduct of the police officers involved. I indicated at the conclusion of the inquest that, based on the evidence before me, I would not be making any adverse comments about the conduct of the police. I am satisfied all of the police officers involved did everything they could to convince Michael to return to the safety of the balcony, but sadly they were unsuccessful. I am satisfied Michael had made up his mind about what he was going to do before the police even arrived at the scene. The position he had placed himself in then made rescuing Michael against his will impossible, and despite the negotiators best efforts, Michael’s mind remained unchanged.2
Michael’s parents also raised some concerns about what was happening for their son in the time leading up to his death that might have caused him to take this drastic action, in particular in relation to issues around his former employer and his new employment. To a limited extent, these issues was also explored at the inquest. The evidence was conflicting and makes it difficult for me to reach any significant conclusions about the issues preying upon Michael’s mind at the time of his death. While there is evidence that some concerns had been raised about his new employment and a meeting was to be held, it’s not clear if Michael was aware of these concerns. There is also evidence he had been experiencing mental health issues for a number of months, so whatever led him to make that decision on the day of his death occurred on a background of other 1 Section 22(1)(c) Coroners Act 1996 (WA) 2 Sections 22(1)(a) and 25(3) Coroners Act 1996 (WA).
[2024] WACOR 22 personal issues that Michael had been experiencing. Accordingly, I am unable to conclude that any one thing led Michael to make that fateful decision. This is often the case in deaths by suicide, as the reasons for suicidal ideation can be complex and it is rare for there to be one singular cause.
Michael was born and raised in Perth. He had no known significant physical or mental health issues growing up. After finishing school, Michael completed a traineeship with the Crowne Plaza Hotel in Perth and then pursued a career in hospitality by working in a number of hotels throughout Australia.
There is evidence Michael worked in Darwin for a time, where he wasn’t looking after himself and drinking a lot. He apparently experienced a bout of pneumonia and was hospitalised for three weeks in 2016. He eventually returned to Perth and started to work on improving his health.3
Michael’s family reported that as far as they were aware, he had no known history of mental health issues. They were aware Michael had a past history of reliance on sleeping tablets, although they also believed he had managed to get it under control.
Michael had recently lost weight by adopting a healthier lifestyle. Michael’s parents were away interstate at the time of his death and his brother had not seen him recently as Michael had been in isolation, so they could not assist with his mental state in the days prior to his death.4
Michael was known to drink alcohol and dabble in drugs recreationally and sometimes gamble at the casino, but he had no criminal history and no history of anti-social behaviour. He had apparently been in a relationship that ended at least a few months before his death. There was evidence that this had, understandably, caused him some emotional distress, but not to the level that, on its own, would make him have thoughts of harming himself.5
Michael’s last long-term employment was at a hotel called The Sebel West Perth Aire Apartments (The Sebel) in Murray Street, Perth. Michael worked through the period of the COVID-19 pandemic, which is well known to have been a very difficult time for everyone and had some particularly difficult implications for the hospitality industry.
However, he had made it through and stayed employed and productive in a challenging time. In late 2021, Michael was reportedly offered a job with another hotel chain, managing some hotels in the North of WA. The role was a significant promotion, so he resigned from The Sebel in order to pursue that opportunity. Michael’s friend, Scott McKinloch, was working with Michael at The Sebel West Perth and recalled Michael was excited about the new opportunity.6
4 Exhibit 1, Tab 22.
5 Exhibit 1, Tab 22 and Tab 24.
6 Exhibit 1, Tabs 12, 13, 22 and 24.
[2024] WACOR 22 unclear, the new job didn’t eventuate, or at least was delayed, and Michael ended up looking for work.7
Michael eventually obtained a new position with Realmark Commercial (Realmark) as the Building Manager for Aire Apartments in March 2022. The Aire Apartments building has 21 floors, with The Sebel, where Michael previously worked, occupying the bottom four floors of the building. The other floors above contain private apartments. Realmark had been the building agent and strata management agent for the apartment complex when Michael had worked at The Sebel, and he had come to know some of the Realmark staff well while in that role. They had become aware Michael was looking for work and, given his extensive experience, were keen to employ him in the role.8
It is apparent that the end of his relationship and then a period of unemployment had a negative effect on Michael, so getting the new job was a very positive step for him. It is, therefore, very surprising that he ended up taking his own life on the first day of his new job. To understand the complexities of these events, it is necessary to look back on what is known about Michael’s mental health in the months leading up to 17 March 2022.
It seems that Michael had begun to experience a decline in his mental health in late 2021, around the time he became unemployed and his relationship ended. Michael was described as a “pretty private person,”9 and he does not appear to have shared much of what he was experiencing with his family or friends.10
Around 14 December 2021, Michael had a meeting with a solicitor at Pragma Lawyers.
Michael had obtained a recommendation for Pragma Lawyers from a friend and work colleague, Luke Downie (Mr Downie), who worked at Realmark. Mr Downie had given Michael the name of a lawyer at his request, but Michael had not told him why he wanted to seek legal advice. Mr Downie recalled that Michael had asked him for the referral a short time before he left the Sebel.11
Michael appeared to make a reference to an earlier incident with the police, suggesting they thought he was a drug dealer when he was about 20 years old. I deal with this more below, but in brief it appears that his prior belief was a psychotic delusion. Michael also suggested the police watching him now were corrupt. Although Michael’s allegation appeared a little “far-fetched,”12 the solicitor also noted Michael appeared to be a reputable, fully functioning, business man, so the lawyer thought it was appropriate to investigate it further. Pragma Lawyers had planned to contact the WA Police Integrity 7 Exhibit 1, Tab 17.
8 Exhibit 1, Tab 13 and Tab 22.
9 Exhibit 1, Tab 12 [4].
10 Exhibit 1, Tab 12.
11 Exhibit 1, Tab 16 and Tab 23.
12 Exhibit 1, Tab 16, p. 1.
[2024] WACOR 22 Unit at Michael’s request, but ultimately they did not take the matter further as Michael did not pay the initial costs into trust that was required, prior to them commencing work on his case.13
The WA Police have confirmed that Michael was not the subject of any investigation or police surveillance.14 It appears these paranoid beliefs may have been a symptom of a developing psychosis. Michael had experienced a similar episode of paranoid thoughts in relation to police conduct in April 2011. On 22 April 2011, Michael had presented to Mirrabooka Police Station and admitted he had taken 20 to 30 dexamphetamine tablets (which he was not prescribed) over a period of about 10 hours in order to “stay awake”15 and he had also drunk alcohol. Michael had reportedly gone to a neighbour’s house as he believed the police were watching him and the neighbour had suggested he was delusional and should go to the police station. At the police station, Michael expressed self-harm ideation, so he was taken by police to the Sir Charles Gairdner Hospital (SCGH) Emergency Department for medical assessment.16
The medical notes indicate that Michael was living with his parents at the time, but they were away on holiday. Michael told SCGH health staff that he still believed the police were following him. Michael was reviewed by a Psychiatric Liaison Nurse and denied any past mental health history, although he admitted he had previously had thoughts of suicide, including wanting to stab himself in the heart with a bread knife. He was seen by a psychiatric registrar and based on his observations and the history he provided, Michael was diagnosed with drug-induced mental disorder. He was discharged home a few hours after he first presented, with a recommendation he see his general practitioner for follow up.17
Although the SCGH Discharge Summary appears to have been addressed to Michael’s usual GP practice, Fitzgerald Medical Practice, their electronic records only run from 2021, so there is no evidence of whether he did seek GP follow up after this incident. It doesn’t appear that he disclosed the incident to his parents on their return home.18
Michael had ongoing issues with chronic insomnia and he had been taking the sleeping medication Stilnox (zolpidem) regularly since at least 2020. On 18 February 2022, Michael contacted his regular GP, Dr Elizabeth Sinclair (Dr Sinclair) at Fitzgerald Medical Practice. He telephoned the medical practice and requested a repeat prescription for his zolpidem sleeping medication and indicated he would come and collect it. Dr Sinclair declined his request as Michael had only recently received a prescription from her with two repeats on 1 February 2022.19
Four days later, on 24 February 2022, Michael consulted with a different GP, Dr Shweta Reddy (Dr Reddy), at Cambridge Medical Practice. It was the first time he had consulted Dr Reddy. Dr Reddy was in the process of completing her GP training but was already a very experienced medical doctor with many years of experience in 13 Exhibit 1, Tab 15, Tab 16 and Tab 22.
14 Exhibit 1, Tab 22, p. 7.
15 Exhibit 1, Tab 21, SCGH ED Medical Notes, Sheet 1.
16 Exhibit 1, Tab 21.
17 Exhibit 1, Tab 21.
18 Exhibit 1, Tab 17.
19 Exhibit 1, Tab 17.
[2024] WACOR 22 various areas of practice. In particular, Dr Reddy had recently spent some time working in the Mental Health Ward at Joondalup Health Campus and in the Emergency Department at Joondalup Health Campus covering the Mental Health Admissions Unit, so she was well placed to assess any mental health concerns Michael might raise.20
Michael seemed generally well but presented with issues of insomnia and anxiety. He told Dr Reddy he had recently changed jobs due to stress at work and had a job interview the next day. He was anxious about how things would work out with the job situation and this was causing poor sleep and low mood.21
Given Michael had presented with some mental health issues, Dr Reddy conducted a risk assessment. She noted Michael was well kempt, with good eye contact and normal speech. He denied having any auditory or visual hallucinations, delusions or irrational fears. Michael denied any suicidal thoughts and appeared to be positive and to have good insight. He also denied any substance abuse history and said he was not experiencing any relationship problems. Dr Reddy diagnosed Michael with anxiety and insomnia. She assessed his risk low and did not identify any red flags.22
She discussed various medications with Michael and he indicated that he wished to “trial” Stilnox (zolpidem). He did not disclose to Dr Reddy that he already had a prescription for Stilnox (zolpidem) from Dr Sinclair and had been refused a new prescription by her a few days before this appointment. Dr Reddy gave evidence that she would not have prescribed such medication to Michael if she was aware he had recently obtained a prescription, without that knowledge, Dr Reddy did advise Michael she would not give him more than a two week prescription of Stilnox (zolpidem), in accordance with therapeutic guidelines, noting it can be addictive. Dr Reddy also suggested he consider starting anti-anxiety medications after the interview, as well as counselling and sleep hygiene. Michael indicated he would think about counselling.
Michael was given a limited prescription for seven Stilnox (zolpidem) tablets only and supplied with information about support services. Follow up was arranged for one week, based on the one week Stilnox (zolpidem) prescription, with a plan to assess how he was going and release the other seven tablets if he was managing well.23
21 T 38; Exhibit 1, Tab 18 and Tab 29.
22 T 39 - 40; Exhibit 1, Tab 18 and Tab 29.
23 T 41 - 43, 51; Exhibit 1, Tab 18 and Tab 29.
[2024] WACOR 22 insomnia and anxiety. Dr Reddy also planned to discuss further doing a mental health care plan to refer Michael for counselling sessions.25
On 3 March 2022, Michael saw another different GP, Dr Syed Shah (Dr Shah), at St Francis Medical in Subiaco. He had been to the practice in the past for treatment for various ailments, including insomnia, and had been given prescriptions for Stilnox (zolpidem) previously. Michael hadn’t been to the practice for over six months when he attended the appointment with Dr Shah in early March 2022. The records indicate Michael discussed with Dr Shah his sleep issues and the fact he usually worked in hotel management and had been stressed while jobless. Michael told Dr Shah that he was starting a new job on the Tuesday and wanted help with his sleep disturbance. The medical notes indicate Dr Shah gave Michael a warning about the risks of long term use of the medication, before giving him a new prescription for Stilnox (zolpidem), indicating he should take one table in the evening as needed.26 It appears Dr Shah was unaware Michael had recently been given prescriptions for the same medication by other doctors.
On 8 March 2022, Michael tested positive to COVID-19 and self-isolated at home for the next seven days. On 9 March 2022, Michael called Fitzgerald Medical Practice and advised staff he was COVID positive and needed another prescription for Stilnox (zolpidem). He had last received a prescription from that practice on 1 February 2022, as Dr Sinclair had declined his next request on 18 February 2022 as it was too soon based on his previously issued prescription. Dr Sinclair was apparently not available on 9 March 2022, so the request was referred to one of her colleagues, Dr Mark Edelman agreed to write another prescription and the notes indicate it was arranged that Michael’s mother would attend the practice and collect it for him, although it’s unclear if this ever occurred.27 Michael sought this prescription only six days after seeing Dr Shah for the same purpose, and after being given a very limited supply by Dr Shah for good reason.
The Therapeutic Goods Administration imposed a boxed warning on Stilnox (zolpidem) on 21 February 2008 following continued Australian reporting of bizarre and sometimes dangerous sleep related behaviours in some users of Stilnox (zolpidem). The boxed warning alerted users to these possible complex sleep-related behaviours and also indicated that Stilnox (zolpidem) is not to be taken with alcohol and its use should be limited to four weeks maximum under close medical supervision.28 The anecdotal evidence suggests Michael was consuming alcohol sometimes while taking Stilnox (zolpidem), although rarely. The medical evidence clearly indicates he had been taking Stilnox (zolpidem) for a prolonged period and he was obtaining multiple prescriptions in the months prior to his death and likely taking above recommended doses. This evidence raises a concern about whether Michael’s consumption of the medication negatively affected his mental state. In particular, Dr Reddy gave evidence that hallucinations can be a rare, but known, side effect of the medication.29 However, the evidence from a psychologist set out below more strongly suggests that Michael was experiencing psychosis due to another cause and was self-medicating with the Stilnox 25 T 44 – 45; Exhibit 1, Tab 18 and Tab 29.
26 Exhibit 1, Tab 25.
27 Exhibit 1, Tab 17.
28 Exhibit 1, Tab 19.
[2024] WACOR 22 (zolpidem) to deal with his racing thoughts and insomnia, rather than it being the cause of his symptoms.
However, it seems Michael did reflect on her suggestion and eventually follow her advice.30
After finishing his seven days of isolation, Michael took steps to arrange an appointment with a private psychologist. He made the booking online via Health Engine on 15 March 2022 and attended the appointment that same afternoon.31
Michael saw Registered Psychologist, Ms Tenille Struthers (Ms Struthers). Michael told her this was his first time seeing a psychologist. Michael said he had sought psychological counselling for highly distressing auditory hallucinations, which had become more persistent and pervasive during his seven day COVID isolation. Michael described the voices as mostly adult male police officers who were illegally surveilling him in the apartment next door, particularly while he was in the bathroom. They accused him of crimes. The voices did not ever tell him to harm himself or others.
Michael mentioned that when he was alone in the bathroom he would hear the voices more so than anywhere else.32 Michael had come to recognise that the voices were not real.33 Michael told Ms Struthers that in “an attempt to suppress these negative voices and physiological reactions at night”34 he self-administered Restavit (doxylamine – an over the counter antihistamine) and Ambien (zolpidem – which he obtained on prescription from doctors).35
31 T 77 - 78; Exhibit 1, Tab 20.
34 Exhibit 1, Tab 20, p. 1.
35 T 77 - 78, 82; Exhibit 1, Tab 20.
36 Exhibit 1, Tab 20.
37 Exhibit 1, Tab 20, p. 1.
Michael had completed a questionnaire at the start of the session and his score indicated a level of psychological inflexibility. She delivered psychoeducation on ‘fight and flight’ response to educate Michael that his experience of anxiety is the body’s automatic physiological reaction to a stressful event or perceived threat, such as the auditory hallucinations. She felt he would benefit from ongoing therapy and recommended he see a GP to prepare a Mental Health Care Plan, which would assist with funding further psychological sessions. Ms Struthers gave evidence that Michael’s distress about the voices and paranoia about being caught was very strange, given the described circumstances, and she planned in future sessions to tease that out a lot more and make sure that the voices weren’t telling him to hurt himself or others. However, at that stage he had given no indication this was the case.39
Ms Struthers expressly explored any current thoughts of suicide with Michael. Michael denied any suicidal ideation or tendencies towards self-harm. His protective factors included starting a new job and support from family and a colleague. Nevertheless, Ms Struthers provided Michael with Lifeline’s 24 hr crisis support number, just in case.
She was expecting to see him for another appointment a week later on 22 March, but sadly Michael died two days later, so he did not see Ms Struthers again. Ms Struthers gave evidence she was very shocked when told about Michael’s death a few days later.40
On 16 March 2022, the day after seeing Ms Struthers, Michael followed up on her recommendation and returned to see a GP to get a referral. He booked an appointment to see Dr Reddy for the third time. Michael requested a Mental Health Care Plan in order to see one of his two preferred psychologists, being Ms Struthers or another psychologist at the same practice. It doesn’t appear Michael revealed he had already seen Ms Struthers the day before, so Dr Reddy had no information about what had been discussed at that first psychological session. In particular, Dr Reddy was unaware at that time of Michael’s history of delusions and auditory hallucinations, that he had disclosed to Ms Struthers that he was hearing voices that had increased in persistence during his COVID isolation and were exacerbating his insomnia. Michael specifically denied any delusions or hallucinations and told Dr Reddy everything remained the same from his previous appointment with her, namely that his anxiety was connected to his job situation and his insomnia was his primary concern. His mental health score at the time of the consultation was in the low range and indicated no distress.41
Dr Reddy gave evidence that if Michael had mentioned auditory hallucinations and paranoia, they fall in a high risk category and she would have referred him to an emergency department for immediate psychiatric assessment, potentially with a call to a family member to take him there. However, without Michael disclosing that information to Dr Reddy, he showed no other signs that he was potentially experiencing psychosis.42
Dr Reddy completed a detailed Mental Health Care Plan for Michael and entered a diagnosis of anxiety. Based on his answers to a psychological questionnaire, Michael seemed able to be managed in the community and there were no red flags. At his
40 T 82 - 83; Exhibit 1, Tab 20.
41 T 47; Exhibit 1, Tab 18 and Tab 29.
[2024] WACOR 22 request, Dr Reddy referred Michael back to Ms Struthers for “opinion and management of anxiety.” Dr Reddy also provided a prescription for melatonin, which is a natural sleep aid and gave him further advice on good sleep hygiene. Michael denied any suicidal thoughts but was again given ‘safety net’ information such as Lifeline support numbers and he was told he should go to an Emergency Department if he felt unwell, including feeling suicidal or delusional. Dr Reddy planned to review Michael again in three months’ time, after he had completed his subsidised sessions with the psychologist, in order to see how the counselling was going. Dr Reddy did not have any further contact with Michael.43
Noting she had seen him the day before he died, Dr Reddy gave evidence the circumstances of Michael’s death absolutely surprised her. Reflecting back on her interactions with him, which were largely based upon her notes but also some personal recollection of seeing Michael, Dr Reddy did not see anything that would have suggested to her that Michael was actively suicidal.44
In hindsight, Michael may have benefitted from a referral to an emergency department to be reviewed by a psychiatrist given he was experiencing auditory hallucinations. It seems most likely he was suffering psychosis from an undiagnosed psychiatric condition. However, he chose not to disclose this information to any of the GP’s that he visited. While he did disclose this information to the psychologist, Ms Struthers, she gave evidence she did not deem Michael to be an emergency case as there were many protective factors and he had agreed to go and see a GP to have a Mental Health Care Plan prepared. His hallucinations were not command hallucinations and he disclosed no suicidal ideation, so there was no obvious immediate risk. Ms Struthers believed Michael was minimising his substance use and that had been her planned focus for future sessions. Given his history of drug-induced psychosis, she felt a harm minimisation approach to drug and alcohol use might be effective. She also advised him to go to an emergency department if he was feeling unwell or suicidal, as did at least one of the GP’s he was seeing. Michael had been on anti-psychotic medication in the past, so he knew this was an option he could pursue.45
I also acknowledge that in reality, even if Michael had been referred to an emergency department at the time, I am aware from other coronial matters that there was a high chance Michael would not have been allocated a mental health bed immediately, as he did not appear to present any risk to himself or anyone else. It is entirely possible he would simply have returned to the community with a recommendation that he see a GP for further management on a Mental Health Care Plan. That is particularly likely, given Michael seemed reluctant to disclose what he was experiencing to the doctors he consulted. Therefore, although there was a small window of opportunity for Michael to be referred for psychiatric evaluation in the day or so before his death, it is difficult to say whether it would have impacted the outcome in this case.
43 T 48 – 50; Exhibit 1, Tab 18.
As noted above, Michael had previously worked for The Sebel West Perth located in the Aire Apartments complex. I understand he performed the role of General Manager for the hotel. Michael’s friend Mr Downie worked for Realmark Pty Ltd. They had met through their roles within hotel and apartment management, as Realmark manages the Aire Apartments building complex. Mr Downie helped Michael obtain his new job as the Building Manager at Aire Apartments. Mr Downie also helped Michael find an apartment to rent in Hay Street, Perth, where he lived alone prior to his death.46
Ryan Henderson (Mr Henderson) also works for Realmark and at the time was the Director of Facilities Management for the company. He also knew Michael from his time at The Sebel and was involved in hiring Michael for his new position, along with Mr Downie. In his new role, Michael would report to Mr Henderson through the building management team.47
Brendan Gomes (Mr Gomes) was the Director of The Sebel West Perth when Michael worked there and was still in that role in March 2022 when Michael was employed by Realmark. Mr Gomes gave evidence at the inquest that he had a good working relationship with Michael in the past and had known him for four or five years.
Mr Gomes was based in the eastern states and would usually travel to Perth for site meetings every month and see Michael at those times, although that obviously stopped during the COVID-19 pandemic when the WA borders were closed and from then he communicated with Michael by telephone. Mr Gomes maintained they had a very good and transparent working relationship and he did not have any issues with Michael. Mr Gomes gave evidence Michael resigned from The Sebel to take up a new position elsewhere.
Mr Downie recalled that about two weeks before Michael commenced in his new job as the Building Manager, Mr Downie called Mr Gomes, in his role as the Director of The Sebel and a member of the Council for Aire Apartments, and advised him that he had appointed Michael to the new role. He was aware Mr Gomes knew Michael very well through his previous employment with The Sebel and knew that Michael had acted as Mr Gomes’ proxy on the Aire Apartments council of owners in the past. Mr Downie recalled that Mr Gomes expressed some concern about the appointment, but did not explain why.48
Mr Gomes initially told police that at the regular monthly meeting of the Aire Apartments council of owners, he advised of Michael’s appointment to the new role and some council members expressed concern. The concerns were raised in the context of Michael, Mr Gomes and Mr Downie all having worked very closely together in the past when Michael worked for The Sebel. Mr Gomes told police that it was suggested by council members that Realmark and Mr Gomes would together have a monopoly over the building if Michael commenced in that position.49 46 Exhibit 1, Tab 23.
48 Exhibit 1, Tab 23.
49 Exhibit 1, Tab 24.
Mr Gomes gave evidence at the inquest that there were issues with the clarity of the position that Michael was going to perform, in terms of whether he was the concierge or the building manager, or both. He said he had not actually had the meeting with the council, but had anticipated members of the council would raise concern. It was in anticipation of the problem that he pre-emptively called for a meeting between the council of Aire Apartments and Realmark.50
Mr Gomes maintained that he did not call for a meeting because he personally had any issues with Michael starting in the role. He said that Michael had left The Sebel on “great terms”51 and only left because he had found a job on a bigger scale with another company in a job similar to Mr Gomes’ own position. It involved a significant pay rise as part of the promotion and Michael was excited about it. Mr Gomes was still unable to return to Perth when Michael left his role at The Sebel, so the handover and transition had been done over the phone and Mr Gomes had not seen Michael face-to-face.52
Mr Gomes said he was unaware of the reasons why Michael did not end up staying in the new role with the company that he left The Sebel for, and didn’t have any communications with him about his new employment until he was informed by Mr Downie that Michael was about to start in the role. He said he was surprised to hear Michael had taken the position in building management as it was a significant pay drop and he believed Michael could easily picked up another hotel manager position in Perth or interstate. However, he thought it was possible Michael had decided to change careers into strata management instead of hotel management, and was going to work his way up from the new position.53
Mr Gomes gave evidence that he wanted to have a meeting with the council so he could make sure they were aware of Michael’s employment by Realmark and confirm they approved of it. He reaffirmed that he did not anticipate it would be a concern about Michael personally, but rather around the inside knowledge Michael had gained in his previous role with The Sebel in relation to the segregation of strata management costs between The Sebel and individual apartment owners. The strata costs for the individual apartment owners had recently increased due to previous errors in the way the costs were calculated, with too much of the cost apportioned to The Sebel, and this was an ongoing issue.54
In terms of Michael’s mental health, Mr Gomes gave evidence Michael had told him he abused alcohol when he was working in Darwin, which seemed to be part of the hospitality industry in that region. However, Mr Gomes understood when Michael had returned to Perth he had given up drinking and slowly recovered, taking a lower position and working his way up to the position of General Manager after he “built his confidence.”55 He was aware Michael had broken up with his girlfriend, which had been a setback that had affected him, but overall he hadn’t been aware of any significant issues going on in Michael’s life. Mr Gomes said in evidence that he had seen Michael briefly in person once towards the end of COVID, when he had flown to Perth for about
[2024] WACOR 22 12 hours before the borders were closed again. Mr Gomes had noticed that Michael had lost weight, which Michael said was due to a change in his diet, but they did not have time to talk about much else going on in Michael’s life.56
Mr Gomes also indicated that he was not expected Michael to lost his job as a result of the meeting, as he understood that it was Realmark’s decision to hire him and they had been short of staff and would understandably have been very happy to secure a new employee with Michael’s experience. However, Mr Gomes said he “wanted to set some boundaries”58 to prevent any complaints arising about a supposed monopoly being created.59
However, another witness, Mr Henderson, who was Michael’s new manager at Realmark, told a different story about the circumstances around the calling of the meeting. Mr Henderson agreed with Mr Gomes’ view that the position Michael had accepted was a step down from his previous roles and Realmark were happy to be able to employ someone with Michael’s qualifications and experience in the role. Realmark management understood that Michael would be wanting to work his way up the ladder quickly and Mr Henderson knew he would need to find a better position for Michael in due course. However, in terms of the concerns raised by Mr Gomes, Mr Henderson’s recollection was that the council of owners at Aire Apartments had already been consulted about Michael’s employment and the response had been very positive as Michael knew the building well and was well regarded by the council of owners.60
Mr Henderson gave evidence that from Realmark’s perspective, Michael was considered a great candidate. They acknowledged that he had accepted a role that was lower pay than his previous employment. They had pitched to Michael that he could expand from this role into a career that could ultimately lead to him overseeing their building management division.61
Mr Henderson said that he didn’t know Michael very well personally, other than as a work acquaintance, but he had formed the view that Michael was “confident” 62 and “really switched on”63 and would excel in the new role. He knew Michael as quite a private person, so he was unaware of any of his personal history at the time he was employed by Realmark, but Mr Downie had formed a friendship with Michael and did not raise any concerns. Indeed, Mr Downie was actively involved in hiring Michael.
From a physical point of view, Mr Henderson was aware Michael had lost some weight
62 Exhibit 1, Tab 13 [5].
[2024] WACOR 22 and he indicated he had stopped drinking alcohol and taking steps to improve himself.
Michael looked very fit and healthy and said his mind was really clear, so from an external assessment, it seemed like Michael was in very positive place.64
Mr Henderson said he did not think the meeting was called because there were any issues with the council of owners at all, as the council had already been informed and the members were very positive about Michael’s appointment and somewhat perplexed as to why the meeting was being called. Mr Henderson said he thought “the voting monopoly thing was rubbish,”66 given how Michael had previously voted when acting as proxy.
Instead, Mr Henderson’s recollection was that the real reason for the meeting revolved around Mr Gomes having issues with some of The Sebel staff and their relationships with Michael from the time when he worked at The Sebel. Mr Henderson had spoken to Mr Gomes and Mr Gomes expressed concerns that some of his staff members were a bit upset that Michael was coming back and there was even a suggestion some were “shaking,”67 which Mr Henderson said took the Realmark staff by surprise.
Mr Henderson noted that the concerns were raised quite late in the piece and Mr Henderson was not convinced of the veracity of the claims. Mr Henderson knew that Michael was really well regarded by the owners council and knew Michael had always acted fairly and reasonably when voting on the council. Mr Henderson considered Michael coming back to the building was very beneficial for all of the council members and he wasn’t convinced that the allegations of issues with some Sebel staff were a compelling reason to reconsider Michael’s position. Mr Henderson gave evidence that he and the other Realmark staff were backing Michael and were not reconsidering their job offer. They had thought long and hard about hiring Michael and had a strong plan for his career path in the company. Mr Henderson said he felt uncomfortable about the meeting being called and his ‘gut feeling’ was that there was a little bit more to what was happening than what he was being told by Mr Gomes, but he did not know anything more and didn’t have a chance to explore it further with Michael before he died.68
There is other evidence from Mr Downie that Mr Gomes had rung Mr Henderson and arranged a meeting with Mr Gomes, Mr Gomes’ lawyer, the council of owners, Mr Downie, Mr Henderson and Michael. The meeting was supposed to take place on 18 March 2022, the day after Michael’s first day on the job. Mr Gomes was apparently already on a plane to Perth to attend the meeting that morning. Mr Downie was not certain whether Michael had been told about the planned meeting before he died. He, like Mr Henderson, was very supportive of Michael remaining in the new position.69
69 T 28, 34 - 35; Exhibit 1, Tab 23.
On Thursday, 17 March 2022, Michael commenced his first day as Building Manager at the Aire Apartments. He arrived at the building at 7.30 am and at approximately 9.00 am he met up with Mr Henderson, and another work colleague, John Cockerill (Mr Cockerill). The three men held a meeting together at a nearby coffee shop.
Mr Henderson recalled Michael on that day was not the “really polished person”71 that he knew from the past, as he appeared nervous, on edge and shaky during the morning meeting. Mr Henderson was aware that Michael had just come out of COVID isolation and Michael explained he was nervous as he was starting a new job after not working for three months.72 It seemed reasonable to Mr Henderson that Michael might be nervous after a few months out of work and having to go back to a former workplace in a different role, so it didn’t raise any particular concerns. Mr Henderson recalled that they had a really nice conversation for about 45 minutes and both he and Mr Cockerill were really excited to have Michael on board.73
Mr Henderson did not recall any discussion about Mr Gomes calling a meeting during this morning coffee conversation. He did say that he assumed that they would have flagged that he was coming back to the building in a different role and queried how he felt he would go with Mr Gomes, knowing that when Michael left the Sebel he would have left a big hole for them, so he assumed that relationship was going to be “a little uncomfortable.”74 However, the conversation did not go beyond that. Mr Henderson gave evidence that he would not have discussed anything more about the new concerns raised by Mr Gomes, as Mr Cockerill was also present at the meeting and it would not have been the right environment to start that kind of conversation with him there as it was too personal. Their meeting that morning was just to help Michael settle in before he started his first shift.75
The question as to whether Michael was aware of the meeting being planned by Mr Gomes, and whether this may have affected his mental state, unfortunately remains unanswered. What is clear is, if he was aware, it was not mentioned on this morning and Michael had turned up for his first day at work and did not discuss it with Mr Henderson and Mr Cockerill.
After about an hour together, the three men walked back from the café to the reception area of Aire Apartments. Michael was given the building management mobile and they
72 Exhibit 1, Tab 13.
[2024] WACOR 22 showed Michael some things on the front desk computer. Mr Henderson left the building at 10.24 am and Mr Cockerill left at 10.31 am. They left Michael to continue with his work in his new role and they held no suspicion that anything was wrong at the time they left. Mr Henderson gave evidence that in hindsight, Michael had looked like he had “a bit going on in his mind”76 but at the time it was easily attributable to first day nerves.77
There is little evidence before me about what Michael did after the other two men left, as no one seems to have spoken to him, but there is CCTV footage that shows him moving around the building doing a security check. It would be usual for the building manager to check some of the doors and services in the building and make sure everything is safe and secure, but it seems Michael has then gone up to the 21st floor and used his keys to go out one of the doors through a plant room, then made his way onto a ledge outside, with the intention of harming himself. Michael left his phone and other personal items such as his wallet and car keys in the plant room before he went outside, suggesting he had already decided what he was about to do before he went outside.78
At 11.14 am a ‘000’ emergency call was made to WA Police stating that a male person appeared to be about to jump off a building on the corner of Murray Street and Havelock Street in West Perth. Two police vehicles were dispatched at 11.16 am at Priority 2 to attend the location and do a welfare check. The first police officers arrived at 11.22 am and immediately identified a male person standing on the top floor of the Aire Apartments building and looking over the edge of the building. The two police officers headed to the top floor of the building, where the male person appeared to be located. They were assisted by residents as they needed swipe cards to get to the top floor. The other police vehicle arrived soon after and the two police officers set up a street cordon to prevent vehicle and pedestrian traffic from passing below the building.79
The seriousness of the situation and the need for specialist staff, was appreciated immediately, and at 11.28 am WA Police Force Negotiators were requested to attend and a Tactical Response Group team was also dispatched. St John Ambulance (SJA) was also notified shortly afterwards and the assistance of SJA officers was requested.80
While the police were present, another call from a member of the public was received at 11.30 am, advising the male person was screaming and appeared to be about to jump.
The police officers downstairs arranging the road closure observed the male person, who we know was Michael, climb onto a ledge on the wrong side of a section of glass balustrade and then shuffle along the ledge towards the middle of the building. He appeared to be holding onto the glass with both of his arms, with his body facing out from the building. He moved in front of one of the apartment balconies, but on the wrong side of the glass fencing.81
77 Exhibit 1, Tab 13.
78 T 34; Exhibit 1, Tab 8 and Tab 13.
79 Exhibit 1, Tab 8 and Tab 22.
80 Exhibit 1, Tab 9.
81 Exhibit 1, Tab 22.
While waiting for Tactical Response Group (TRG) and negotiator officers to arrive, Constable Mitchell Jolliffe (Constable Jolliffe) and Sergeant Sarah Brookes (Sergeant Brookes) had gained access to the roof and then a plant room with the help of some building contractors who were present. They couldn’t immediately get outside the plant room to where Michael had last been seen as the door was locked. Sergeant Brookes looked under the door and could see Michael sitting on the ledge of the roof of the building. She called out to him and he looked at her but did not respond. They found Michael’s personal items, including his phone and wallet with his identification inside, on the floor of the plant room. This assisted in confirming Michael’s identity.
While the police officers were trying to find a way to open the door, one of the contractors, who knew Michael from working with him previously, crawled under the door and tried to speak to Michael. The police officers couldn’t do that due to their equipment. The contractor then crawled back under the door and advised Michael had moved onto the wrong side of the balcony of an apartment. The police officers tried to gain entry to the apartment, without success.82
Constable Jolliffe then made his way to the roof of the building. From there, he and Sergeant Brookes were able to see that Michael had indeed moved and was now standing on the wrong side of the balcony balustrading of the apartment below. It looked to them like he was seriously contemplating jumping. Sergeant Brookes returned downstairs and left Constable Jolliffe on the roof. She spoke to the contractor who had spoken to Michael. He said he knew Michael from working with him and believed Michael was clearly not in a right frame of mind.83
Constable Jolliffe began to speak to Michael at around 11.39 am. He was positioned about three metres from Michael, elevated above him. Apartment 2102 was locked and the occupier was not present at this time, so the only two persons present were Michael and Constable Jolliffe. Constable Jolliffe recalled Michael did not engage much with him and seemed emotionless and unwilling to provide a lot of personal information. He would not permit Constable Jolliffe to jump down from the roof to the balcony in order to speak to him more easily. Michael did tell Constable Jolliffe to tell his ‘friend’ he was sorry and directed Constable Jolliffe to money in his wallet with words to the effect, “This is to pay for the damage where I land.”84
Constable Jolliffe did eventually manage to elicit a small amount of personal information from Michael, and established that he was reasonably close to his family, but his parents had recently travelled interstate and he had only recently reconnected with his brother and didn’t want him called. His issues did not appear family related but he wouldn’t explain what had caused him to go out onto the ledge. Michael had initially been facing away from the balcony, looking down to the ground, but during their conversation he turned back towards Constable Jolliffe on several occasions, which Constable Jolliffe saw as a positive sign. Constable Jolliffe spoke to Michael for about 20 minutes and asked Michael several times to come back over onto the balcony, but Michael refused.85 82 Exhibit 1, Tab 22, pp. 43 - 44.
83 Exhibit 1, Tab 14 and Tab 22, p. 44.
84 Exhibit 1, Tab 22, p. 18.
85 Exhibit 1, Tab 22.
On Thursday, 17 March 2022, Senior Constable Gary (Gus) O’Loughlin (S/C O’Loughlin) and Senior Constable David Fagan (S/C Fagan) were ‘on call’ as part of the WA Police Negotiator Team that day. Both officers had undertaken extensive training as negotiators, having qualified as police negotiators in 2015 and 2012 respectively after successfully undertaking a rigorous two week training course and then completing a year-long probationary period. Not all police officers are trained as negotiators. It is a specialist qualification that requires both the individual officer to express an interest and for them to then be selected before they are trained. To remain part of the team, they must also continue to complete ongoing minimum training requirements thereafter. S/C O’Loughlin had also undertaken additional training and is a qualified Counter Terrorism Negotiator.
On this day, S/C O’Loughlin was the TRG Primary On-call Negotiator and S/C Fagan was assigned the role of Secondary On-call Negotiator. S/C O’Loughlin had previously attended a significant number of crisis incidences in the role of Primary Negotiator, including suicide intervention incidents, and they had all resolved peacefully. He was considered to be one of the unit’s more experienced negotiators.88
The two negotiators were advised of the incident at about 11.45 am and were dispatched to the scene under priority response conditions, both officers arriving at the scene at about 11.55 am. S/C O’Loughlin went upstairs to speak to the attending police officers and then try to engage with Michael. S/C Fagan initially remained downstairs in order to provide support and coordinate matters for S/C O’Loughlin on the ground, before later joining him upstairs.89
S/C O’Loughlin made his way to the 21st floor and spoke to Constable Jolliffe’s partner, Sergeant Brookes, who gave him a briefing of what had happened thus far.
S/C O’Loughlin then went to try to speak to Michael. Everything S/C O’Loughlin said
87 T 33 – 35; Exhibit 1, Tab 22.
88 Exhibit 1, Tab 22.
89 Exhibit 1, Tab 22.
[2024] WACOR 22 was captured on his Body Worn Camera (BWC). Not all of Michael’s responses were captured, however, due to the distance between them at times.
S/C O’Loughlin first gained access to the roof space near the balcony of apartment 2102 and began speaking to Michael from a level position. While S/C O’Loughlin was talking to Michael, Michael was still standing on the incorrect side of the balcony of apartment 2102, which is on the 21st floor. The apartment was locked and the occupier was not present. S/C O’Loughlin immediately asked Michael to come back over the balustrade back to the safety of the balcony so they could talk, but he declined to follow the direction.
At this early stage, S/C O’Loughlin was positioned approximately six metres from Michael and they were separated by a panel. Due to the distance, the obstruction of the screen and the ambient noise from the surroundings, communication was difficult and it was hard to hear what Michael was saying and to engage properly.90
At the request of the police, the occupant of apartment 2102 returned home at 12.09 pm and permitted the police to access the apartment. S/C O’Loughlin and S/C Fagan entered the apartment and S/C O’Loughlin then went out onto the balcony, which made it easier for him to speak to Michael as they were only about two metres apart, on the same level.91
S/C O’Loughlin’s initial assessment was that Michael intended to hurt himself that day, given his positioning on the balcony, the planning required to put himself in that position and his intent focus on the ground below. S/C O’Loughlin considered whether it might be appropriate to try to physically grab Michael and pull him to safety, but ruled it out as:92 there was a real risk Michael might decide to jump and pull S/C O’Loughlin down with him; the balcony barrier did not look sturdy enough to support two people; because it was hot, it was possible Michael would be slippery and sweaty so taking hold of him would be difficult; and Michael’s legs were shaking and he didn’t seem sure of his footing, so grabbing at him may have inadvertently dislodged him.
S/C Fagan agreed with his assessment.93 Both S/C O’Loughlin and S/C Fagan felt it would require Michael to be convinced to want to come to safety for a successful rescue to occur. Based on the fact that Michael had already been out there for at least 20 minutes and not acted on his desire to hurt himself, there was some small optimism that he could be convinced not to hurt himself. However, based on his first observations, S/C O’Loughlin also thought helping Michael would be difficult, due to his apparent level of intent.94 90 Exhibit 1, Tab 22.
91 Exhibit 1, Tab 22.
92 Exhibit 1, Tab 27.1.
93 Exhibit 1, Tab 28.
94 Exhibit 1, Tab 22 and Tab 27.1.
For approximately two hours from around 12.09 pm, S/C O’Loughlin spoke to Michael from the balcony and attempted to establish some rapport with him in order to negotiate with him to return to the safety of the balcony. S/C O’Loughlin said he used his body language and questions to try to keep Michael’s focus on him but without scaring him or making him agitated. They began talking and Michael spoke about his parents, other family members and friends and expressed his apologies and regret while appearing to say his farewells to them all. It appeared to S/C O’Loughlin that he Michael was trying to use him as a messenger to pass on these messages to his loved ones, which was obviously a disturbing sign.95
During their conversation, Michael did not really articulate the reasons why he was feeling suicidal. He shook his head when asked if it was to do with a break up. He made it clear he loved his parents and it was not their fault but he knew his actions would hurt them. He also apologised to his brother.96
Michael did talk about his new job but later declared his issue was “not work related”97 without elaborating further. He told S/C O’Loughlin to tell Mr Downie and Mr Henderson “sorry and thank you for the opportunity.”98 Michael also later asked that his friend Scott be told he was sorry. It seems he believed he had hurt a number of his friends and said words to the effect, ‘tell them (or him) I’m a psychopath and I lost control. It can’t happen again’ at 1.53 pm. He did not explain further what he means by this statement.99
When questioned, Scott McKinloch (Scott) could only direct police to an incident before Michael finished at The Sebel when Michael had harshly reprimanded him for leaving a cash drawer open. However, Michael had later apologised to him and Scott did not have any understanding why Michael might feel suicidal and did not think it was connected to this incident.100
Considered overall, Michael seemed to indicate he had received some bad news lately, without elaborating further, and S/C O’Loughlin got the impression Michael felt he had let his friends down for some reason or hurt them in some way and he felt the problem could not be fixed.101
Throughout their conversation, Michael repeatedly refused S/C O’Loughlin’s requests to return to the correct side of the balustrading and refused repeated requests to be fitted with a safety line. Michael did, however, seem willing to speak to, and listen to, S/C O’Loughlin and he accepted water from him on the first occasion, at 1.38 pm, without reacting in alarm as he was approached. It was hot and it was apparent Michael was getting fatigued as time passed and he had requested the water.102 95 T 65; Exhibit 1, Tab 27.1.
96 T 66; Exhibit 1, Tab 22, pp. 51 - 52.
97 Exhibit 1, Tab 22, p. 54.
98 Exhibit 1, Tab 22, p. 52.
99 Exhibit 1, Tab 12 and Tab 22.
100 Exhibit 1, Tab 12 and Tab 22.
101 T 66; Exhibit 1, Tab 22 and Tab 27.1.
102 Exhibit 1, Tab 22.
At 12.37 pm, Department of Fire and Emergency Services (DFES) personnel and the TRG Recovery Team advised they could position themselves on the roof space above Michael and they were able to use some anchor points to secure a safety line, in preparation for the safe recovery of Michael from the outside of the balcony, if he was willing. S/ O’Loughlin had checked when he gave Michael the water that the safety gear was in place above him and he then tried to convince Michael to return to the balcony at this time, but Michael continued to refuse.103
Michael spent a lot of time looking down during the negotiations, apparently contemplating what he planned to do next. He was lucid, seemed oriented to time and place and to understand who S/C O’Loughlin was, and why he was there. He didn’t appear frightened of S/C O’Loughlin, just generally distressed. S/C O’Loughlin told Michael he was there to help him and was happy to talk to him about anything that was on his mind, as the first step to getting help. He asked Michael if there was anyone else he’d like to talk to, but Michael didn’t nominate anyone else.104
After having the first drink of water at around 1.38 pm and handing the water back, it appeared to S/C O’Loughlin that Michael suddenly developed a greater confidence to follow through with his plan. S/C O’Loughlin immediately responded by trying to get Michael’s focus back on him. Michael seemed to re-engage for a period It was never entirely clear what had happened that had led Michael to feel suicidal, although his focus towards the end continued to be on having upset his friends. He steadfastly refused the offer of the safety harness and specifically said around 2.01 pm, “I’m not coming over.”
S/C O’Loughlin pointed out to Michael that he had been there for a long time. He suggested that Michael could let him help him over the balcony and they could sit down and talk about it. He said he couldn’t change whatever had happened but there were other options to help him. Michael refused to come over, but did accept another drink of water. It was obvious he was becoming fatigued, which was very dangerous given his precarious position, as there was a risk he would weaken and slip off the balcony.
Therefore, giving him water was important, despite the risks.105
S/C O’Loughlin approached Michael cautiously. He asked Michael to turn around and grab hold of the edge tightly and lean over to receive the water. Michael did as requested and was given the bottle of water.
At 2.07 pm, after drinking from bottle of water for the second time, he handed it back to S/C O’Loughlin, Michael then turned and said what appeared to be ‘Goodbye Gus’ and 103 Exhibit 1, Tab 22.
104 Exhibit 1, Tab 22.
105 Exhibit 1, Tab 22, Tab 27.1 and Tab 28.
[2024] WACOR 22 he then let go of the balustrade railing and pushed himself with his legs away from the balcony.106
Michael died instantly from injuries he sustained in the fall. At 2.12 pm, after being assessed by SJA officers, Michael was formally declared life extinct. 107
An investigation immediately commenced into Michael’s death. The investigation was conducted by officers from the Coronial Investigation Squad and the Forensic Field Office under the Coroners Act, as well as Internal Affairs Unit officers as it fell within the definition of a ‘Critical Incident Involving Police’ requiring their attendance.
Michael’s car was located in the building and his Mental Health Care Plan was found in it, which prompted the police to seek Michael’s medical records, which are outlined above. Unfortunately, the police did not go to Michael’s unit to check that there was no additional information there about Michael’s state of mind, but I assume that if there had been, Michael’s family would have raised it as they have been very proactive in providing relevant information to the police and the Court.108
Based on the information available, in conjunction with an external post mortem examination and CT scan, a forensic pathologist, Dr V. B. Kueppers (Dr Kueppers), determined a full post mortem examination was not required to form an opinion on the cause of death. The external and CT examinations showed the presence of multiple severe injuries to the head, chest and other parts of the body. COVID-19 positivity was confirmed on post mortem serology testing, consistent with the history of Michael’s recent positive test and period of isolation.109
Limited toxicology analysis detected no alcohol or illicit drugs. Several medications were detected at non-toxic levels, including diphenhydramine, doxylamine, ibuprofen and paracetamol. Zolpidem was not detected but there was evidence before me that it has a very short half-life and gets completely eliminated from the system in 12 hours, so he could have taken it the night before and it have been gone by the following day.110
At the conclusion of the limited post mortem investigations, Dr Kueppers formed the opinion the cause of death was multiple injuries.111 I accept and adopt Dr Kueppers’ opinion as to the cause of death.
The other evidence before me all supports the conclusion that Michael died by way of suicide, and I so find. Although the evidence suggests he was most likely suffering psychosis at the time, there is nothing to indicate that he was unable to appreciate the nature and consequences of his actions.
106 Exhibit 1, Tab 22.
107 Exhibit 1, Tab 10, Tab 11, Tab 22 and Tab 27.1.
108 T 56 – 58; Exhibit 1, Tab 22.
109 T 42; Exhibit 1, Tab 4.
110 T 42; Exhibit 1, Tab 4 and Tab 5.
111 Exhibit 1, Tab 4 and Tab 5.
The WA Police Internal Affairs Unit (IAU) conducted its own internal investigation in relation to a number of police officers who were involved in dealing with Michael or managing the incident. The investigation was comprehensive and involved interviewing a number of the officers involved, reviewing body worn camera footage and considering the officers’ conduct against the WA Police Force Policies & Procedures and the WA Police Force Code of Conduct, specifically in terms of considering whether the officers failed to ensure Michael’s welfare.112
The IAU investigation concluded that all officers performed their duties in accordance with their training, the WA Police Force Policies & Procedures and the WA Police Force Code of Conduct.
Specifically in relation to S/C O’Loughlin, Sergeant Craig Reynolds (Sergeant Reynolds), who at the time was the Negotiator Coordinator for the WA Police Negotiators Unit, reviewed the BWC footage capturing S/C O’Loughlin’s engagement with Michael and indicated he could not fault S/C O’Loughlin’s engagement with Michael and believed S/C O’Loughlin “performed at the highest level possible”113 and in accordance with his unit and national training. Sergeant Reynolds expressed his opinion that S/C O’Loughlin is an “exceptional negotiator”114 who is also a very wellliked and respected member of team.115
Sergeant Reynolds, who has extensive experience as a negotiator, could not recall another incident where a person of interest has engaged with negotiators or police for over two hours and then jumped, especially without warning. He considered Michael’s tragic outcome to be very unusual in such circumstances.116
The current Negotiator Coordinator for the WA Police Negotiators Unit, Sergeant Jason Marsh (Sergeant Marsh), also prepared a report in this matter117 and gave evidence at the inquest. Sergeant Marsh agreed with Sergeant Reynolds’ opinion that S/C O’Loughlin could not have done anything more to try to resolve the situation, as the position in which Michael had placed himself made it too dangerous to try to forcibly restrain Michael and move him back to the balcony and all efforts to establish rapport and convince Michael to return to the balcony of his own volition failed.
Sergeant Marsh observed that S/C O’Loughlin’s genuine concern for Michael was evident throughout the negotiations as he pleaded with Michael to give him a chance to let him help and talk through his problems, but Michael generally appeared withdrawn and reluctant to provide much information or engage fully in the conversation. It was difficult for S/C O’Loughlin to problem solve or provide options without knowing what issues Michael was experiencing, and enquiries by other officers to assist in that regard also failed.118 112 Exhibit 1, Tab 22.
113 Exhibit 1, Tab 22, p. 40.
114 Exhibit 1, Tab 27.3, p. 4.
115 Exhibit 1, Tab 27.3.
116 Exhibit 1, Tab 27.3.
117 Exhibit 1, Tab 26.
118 Exhibit 1, Tab 26.1.
Similarly, there was one death in police presence involving police negotiators in 2023 after they attended a total of 198 critical incidents. Many of these incidents involve people like Michael who are threatening suicide, but fortunately, in most cases the negotiators are able to achieve a successful outcome. Sadly, in Michael’s case, that could not be done, but Sergeant Marsh expressed the opinion that both S/C O’Loughlin and S/C Fagan did everything within their capabilities to try to convince Michael there was another path for him that day. He considers that S/C O’Loughlin, in particular, “displayed professionalism, commitment and a genuine desire to help resolve the incident peacefully.”119
Sergeant Marsh, who is involved in national training at this level, also indicated that he is not aware of any police jurisdiction in Australia using any other equipment, such as nets or crash pads, in crisis incidents to safely resolve a case like Michael’s. While there were options available to do vertical rescue roping to retrieve Michael, it required his cooperation to be performed safely and successfully. Given the elevated height, there was nothing else practical that could be implemented on that day to stop him from falling to his death.120
S/C O’Loughlin also gave evidence at the inquest, S/C O’Loughlin indicated he had reflected on this matter, without re-watching the BWC footage due to its traumatic nature, and he had been unable to come up with anything that either individually or as a team could have been done differently that might have changed the outcome.i121
As Sergeant Marsh explained, there are “no dark arts” 122 involved in negotiation; it is ultimately “about having good people who can engage with others.”123 People like S/C O’Loughlin and S/C Fagan volunteer to be trained as they want to help people like Michael, and they are selected because they are good listeners with good communication skills who are able to establish rapport with people in crisis.
Unfortunately, all of those skills were not enough to convince Michael to seek safety and help on this day, but I accept that, even with the benefit of hindsight, there is nothing more that could have been done in this incredibly challenging situation, based upon what they knew at the time. There were thoughts happening inside Michael’s mind that he was not prepared to share with others, but they clearly overwhelmed him on this day. He chose a manner of suicide that he knew would succeed, making it very clear he did not choose to be saved.
119 Exhibit 1, Tab 26.1, p. 7.
120 Exhibit 1, Tab 26.1..
121 Exhibit 1, Tab 27.1.
The medical notes, psychological report and notes from Michael’s meeting with the solicitor provide some insight into the thoughts Michael was experiencing in the months leading up to his death.
The notes taken from the meeting with Pragma Lawyers indicate Michael believed the police surveilling him in his apartment but Michael also indicated he wasn’t worried about his safety.124 Michael’s conversation with the psychologist, Ms Struthers, similarly canvassed his belief that police were surveilling him, but he again did not seem genuinely fearful for his safety, although the delusions were clearly causing him distress and exacerbating his insomnia.
It is possible, in hindsight, that Michael’s delusions in relation to corrupt police behaviour towards him may have affected his response to the presence of police on the day he died. However, this information was not known to the attending police officers at the relevant time and in any event, there is probably not much they could have done about it given the seriousness of the situation. I note that on the previous occasion when he had experienced psychosis and believed police were surveilling him, Michael had still sought help from the police, and when dealing with Pragma Lawyers, he had wanted them to reach out to the police integrity section, indicating he retained trust in the WA Police Force overall. Further, on the BWC footage Michael does not appear fearful of S/C O’Loughlin, who was dressed as a negotiator (not in full uniform) and whom Michael had been invited to call by his nickname ‘Gus’, which he did.
S/C O’Loughlin gave evidence he felt Michael seemed quite comfortable speaking to him that day and did not appear to have any adverse feelings towards police.125
Although he moved position after the first police officers made their way to the roof and started trying to engage with him, it is clear Michael had already formulated a plan and left his personal items in the plant room before heading out to execute his plan.
Witnesses who called police suggested he was already looking over the roof and gave the impression he was thinking about jumping. In my view, the police presence, particularly that of S/C O’Loughlin, probably delayed Michael’s death, rather than caused or contributed to it.
124 Exhibit 1, Tab 15 and Tab 16.
Michael’s death was a tragic event that has had a profound effect on not only his family, friends and colleagues, but also the police officers who attended that day, the many other emergency services personnel and the health practitioners who saw Michael shortly before his death. Michael did not confide in anyone that he was feeling suicidal, so his behaviour took everyone by surprise and has left many unanswered questions.
When the WA Police were notified by members of the public that Michael was on the roof of his workplace and appeared to be contemplating jumping, trained police negotiators were called in to try to help him. The primary negotiator, S/C O’Loughlin, used all his training, skills and experience to try to talk Michael out of what he was planning to do, with the support of his colleagues. It was an extremely challenging negotiation, given the height and Michael’s precarious position on the outside of the balcony. There was no way of bringing Michael to safety without his agreement, but S/C O’Loughlin held some optimism as time went on and it seemed like he was establishing some rapport with Michael, However, he was unaware of the mental health issues Michael had been experiencing for a number of months, which clearly were preying upon his mind, as well as possibly some other issues in relation to his employment and personal relationship. In the end, Michael followed through on his intended plan without ever revealing exactly what was troubling him. I regret that this inquest has been unable to provide Michael’s parents with more answers to what was happening that led Michael to make this choice.
However, my primary task in this inquest was to consider the conduct of the police.
This is not the first time I have conducted an inquest into a death where the WA Police Negotiators Unit was involved, but I can say that these cases are very rare, as fortunately most of the time the negotiators are successful in their aim. The work of the police negotiators is a very important part of the service the WA Police Force provides
[2024] WACOR 22 to the community, which is reflected in the additional resourcing that has been provided to the WA Police Negotiators Unit in recent years. It is an exceptionally rewarding, but also an exceptionally challenging, role to perform. I acknowledge the personal toll a tragic case like Michael’s death takes on the negotiators involved. As I foreshadowed at the beginning, I am satisfied the police officers involved did not cause or contribute to Michael’s death. They did everything in their power to save him.
S H Linton Deputy State Coroner 8 May 2024
A 21-month-old boy died from sepsis secondary to pneumonia complicated by undiagnosed acute lymphoblastic leukaemia (ALL). He presented to ED on 22 March with a three-week history of intermittent fever, had seen three GP…
Brian Kealy, aged 42, died by hanging at Hakea Prison on 2 August 2024 while on remand. He had a complex psychiatric history including polysubstance use, personality disorders, and treatment-resistant psychotic symptoms.…
Sean Theo Winmar, a 46-year-old Nyungar Aboriginal man, died by hanging at The Beacon residential facility on 11 August 2022. He was subject to an interim post-sentence supervision order (HRSO Act) following release from…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries are for educational purposes only and must not be treated as legal documents. Report an inaccuracy.