Deceased
NW
Demographics
31y, female
Coroner
Coroner Jenkin
Date of death
2021-10-09
Finding date
2024-12-02
Cause of death
unlawful homicide (manslaughter); specific cause could not be determined due to post-mortem decomposition
AI-generated summary
NW, aged 31, was killed by her partner on 9-10 October 2021 in Kununurra, Western Australia. She had a history of domestic violence victimization and had obtained a Family Violence Restraining Order. On the evening of her death, her mother called emergency services requesting police take NW to a women's refuge, citing fears of assault. Police received three requests for assistance that night but failed to adequately locate or check on NW's welfare. Key failures included: incomplete enquiries at the initial address, diversion to higher-priority tasks, failure to check CAD Task 1 updates that revealed a possible sighting of NW and her partner, and premature closure of the incident without locating either party. While the coroner found police response inadequate, causation to NW's death could not be established to the required legal standard. Recommendations focused on mandatory use of a supervisor checklist for family violence CAD tasks and making face-to-face family violence training mandatory for all frontline officers.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
[2024] WACOR 51 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : MICHAEL ANDREW GLIDDON JENKIN, CORONER HEARD : 29 - 30 OCTOBER 2024 DELIVERED : 2 DECEMBER 2024 FILE NO/S : CORC 28 of 2021
DECEASED : NW Catchwords: Nil Legislation: Coroners Act 1996 (WA) Restraining Orders Act 1997 (WA) Counsel Appearing: Mr W. Stops appeared to assist the coroner.
Ms R. Paljetak (State Solicitor’s Office) appeared for the Western Australian Police Force.
SUPPRESSION ORDER On the basis that it would be contrary to the public interest, I make an Order under section 49(1)(b) of the Coroners Act 1996 that there be no reporting or publication of the name of the deceased. Instead, the deceased is to be referred to as “NW”.
Order made by: MAG Jenkin, Coroner (29.10.24)
[2024] WACOR 51 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Michael Andrew Gliddon Jenkin, Coroner, having investigated the death of NW with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, Perth, on 29 - 30 October 2024, find that the identity of the deceased person was NW and that death occurred on or about 9 October 2021 at Kununurra in the following circumstances: Table of Contents
NW’s remains were located at Lily Creek in Kununurra on 24 October 2021.2,3,4,5,6 Although NW’s remains were examined by two forensic pathologists and a forensic anthropologist, it was not possible to determine the cause of her death due to post mortem changes.7,8,9
NW’s partner pleaded guilty to NW’s manslaughter and on 17 November 2023 in the Supreme Court of Western Australia, he was sentenced to 11 years’ imprisonment.10
Prior to her death, Police had received three requests for assistance in relation to NW on the evening of 9 - 10 October 2021. For reasons I will explain, I have concluded that the police response to these requests for help was inadequate.
Under the terms of the Coroners Act 1996 (the Act), NWs’ death was a “reportable death”. Further, because a member of the Western Australia Police Force (the Police) may have caused or contributed to NW’s death, a coronial inquest was mandatory.11
I note that section 22(1)(b) of the Act is enlivened whenever the issue of causation or contribution in relation to a death arises as a question of fact, irrespective of whether there is any fault on the part of any member of the Police.12
For reasons I will explain, I have been unable to conclude, to the relevant standard, that any member of the Police caused or contributed to NW’s death.
1 As a mark of respect to the deceased, I referred to her as “NW” at the inquest, and in this finding 2 Exhibit 1, Vol 1, Tab 1, Life Extinct Form (24.10.21) 3 Exhibit 1, Vol 1, Tab 2, P98 - Mortuary Admission Form (24.10.21) 4 Exhibit 1, Vol 1, Tab 3, P92 Identification of deceased person other than by visual means (27.10.21) 5 Exhibit 1, Vol 1, Tab 3, Affidavit - Sen. Const. S Durka (27.10.21) 6 Exhibit 1, Vol 1, Tab 3.1, Coronial Identification Report (26.10.21) 7 Exhibit 1, Vol 1, Tab 4, Supplementary Post Mortem Report (07.02.23) 8 Exhibit 1, Vol 1, Tab 4.1, Post Mortem Report (08.11.21) 9 Exhibit 1, Vol 1, Tab 5, Toxicology report (04.11.21) 10 Exhibit 1, Vol 1, Tab 23, [2023] WASCSR 33, Sentencing remarks per Quinlan, CJ (17.11.23) 11 Sections 3 & 22(1)(b), Coroners Act 1996 (WA) 12 Section 22(1)(b), Coroners Act 1996 (WA)
I held an inquest into NW’s death on 29 - 30 October 2024, and the Brief containing the documentary evidence adduced at the inquest comprised two volumes. The inquest focused on the actions of members of the Police in the period prior to NW’s death, as well as the circumstances of NW’s death. The following witnesses gave evidence at the inquest:13 a. Prob. Const. C. Piahana, Attending police officer (Officer Piahana); b. FC Const. S. Burtnyk, Attending police officer (Officer Burtnyk); c. FC Const. D. Lee, Attending police officer (Officer Lee); d. FC Const. L. Tompkins, Attending police officer (Officer Tompkins); e. A’Sgt. D. Glasson, Supervising police officer (Officer Glasson); f. Det. A’Sen. Sgt. D. Mackay, Author, IAU14 report (Officer Mackay); and g. Supt. L. Hugo, OIC, Family Violence Division, (Officer Hugo).
In assessing the available evidence and considering whether to make any adverse findings, I have been mindful of two key principles. The first is the phenomenon known as hindsight bias, which is the common tendency to perceive events that have occurred as having been more predictable than they actually were.15
The other relevant principle with which I must engage is known as the Briginshaw test. This principle is derived from a High Court judgment of the same name, in which Justice Dixon said: The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding are considerations which must affect the answer to the question whether the issue has been proved to the reasonable satisfaction of the tribunal. In such matters “reasonable satisfaction” should not be produced by inexact proofs, indefinite testimony, or indirect inferences.16
The Briginshaw test requires that the more serious the allegation, the higher the degree of probability that is required before I can be satisfied as to the truth of the allegation.
13 Note: the ranks shown for Officers Piahana, Burtnyk, Lee, Tompkins and Glasson are the ranks they held on 9 October 2021 14 IAU is the abbreviation for the Police Internal Affairs Unit 15 See for example: www.britannica.com/topic/hindsight-bias 16 Briginshaw v Briginshaw (1938) 60 CLR 336 per Dixon J at 362
[2024] WACOR 51 NW Background17,18
NW was born in Katherine in the Northern Territory on 11 June 1990, and grew up there and in Kildurk. NW had no siblings, and was 31 years old when she died on or about 9 October 2021 in Kununurra.19,20
For about 18 months prior to her death, NW was in a relationship with Mr Warrick Walkerbear. NW and Mr Walkerbear had lived in the Northern Territory, but they moved separately to Kununurra in 2021.21,22
NW was described by her mother as “chatty, laughing and happy” when around her family, but “quieter and sad” when she was in the presence of Mr Walkerbear.23 NW’s previous exposure to domestic violence24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39
Prior to her relationship with Mr Walkerbear, NW was in a relationship with a different male which was characterised by incidents of domestic violence.40 NW was declared a recidivist family violence victim by the Police on 17 March 2014, and the alert attached to NW’s name in the police computer states (in part): “Positive police intervention to be taken in relation to all future DV (i.e.: domestic violence) incidents”.41 17 Exhibit 1, Vol 1, Tab 10.1, Statement - NW’s mother (28.10.21) 18 Exhibit 1, Vol 1, Tab 6, IAU Report - Det. A’Sen. Sgt. D Mackay (26.02.24), pp8-9 19 Exhibit 1, Vol 1, Tab 4, Supplementary Post Mortem Report (07.02.23) 20 Exhibit 1, Vol 1, Tab 4.1, Post Mortem Report (08.11.21) 21 Exhibit 1, Vol 2, Tab 2, P100 - Report of Death 22 Exhibit 1, Vol 2, Tabs 38 & 39, Statements - Mr G Bradshaw (20.04.23 & 22.06.23) 23 Exhibit 1, Vol 2, Tab 36, Notes of victimology discussions between NW’s mother and Sen. Const. R Macey) 24 Exhibit 1, Vol 2, Tabs 6-19 & 21-26, CAD and IMS Incident Reports(various dates 27.01.20 - 09.10.21) 25 Exhibit 1, Vol 1, Tab 15, NW’s Medical records - Derby Hospital 26 Exhibit 1, Vol 1, Tab 16, NW’s Medical records - Katherine Hospital 27 Exhibit 1, Vol 1, Tab 17, NW’s Medical records - Kununurra Hospital 28 Exhibit 1, Vol 2, Tabs 38 & 39, Statements - Mr G Bradshaw (20.04.23 & 22.06.23) 29 Exhibit 1, Vol 2, Tabs 44 & 45, Statements - Mr T Carlton (28.10.21 & 16.11.22) 30 Exhibit 1, Vol 2, Tab 46, Statement - FC Const. B Coyle (22.11.22) 31 Exhibit 1, Vol 2, Tabs 51 & 52, Statements - Ms K Jessell (05.11.21 & 15.11.22) 32 Exhibit 1, Vol 2, Tab 57, Statement - Ms T Macale (22.06.23) 33 Exhibit 1, Vol 2, Tab 60, Statement - Sen. Const. R Neville (09.11.22) 34 Exhibit 1, Vol 2, Tab 64, Statement - Ms T Roberts (28.10.21) 35 Exhibit 1, Vol 2, Tab 69, Statement - Mr P Rosewood (20.06.23) 36 Exhibit 1, Vol 2, Tab 71, Statement - FC Const. L Tompkins (27.11.21) & attached photos and Incident Report summaries 37 Exhibit 1, Vol 2, Tab 24, IMS Incident: Breach of FVRO (13.08.21) 38 Exhibit 1, Vol 2, Tab 25, IMS Incident: Assault occasioning bodily harm (28.07.21) 39 Exhibit 1, Vol 2, Tab 26, IMS Incident: Breach of FVRO (01.08.21) 40 Exhibit 1, Vol 2, Tab 71, Statement - FC Const. L Tompkins (27.11.21) and attached Incident Report summaries 41 Email: Sen. Const. C Robertson to the Court (14.11.24)
NW’s relationship with Mr Walkerbear was characterised by repeated incidents of domestic violence, some of which involved very serious assaults on her by Mr Walkerbear.42 In March 2021, NW separated from Mr Walkerbear and moved from the Northern Territory to Kununurra to live with her mother. It appears that Mr Walkerbear subsequently relocated to Kununurra to live with NW at her mother’s house, and his relationship with NW resumed in about May 2021.
At about 1.30 am on 28 July 2021, Officer Tompkins and another police officer attended a family violence incident involving Mr Walkerbear and NW at her mother’s home at 67A Barringtonia Avenue, Kununurra.
When Officer Tompkins spoke to NW, who was lying on a mattress in a bedroom in the front of the home, NW was slurring her words and appeared to be intoxicated. Officer Tompkins also noted that NW had sustained “significant facial injuries”.43,44
However, with NW’s consent, Officer Tompkins took a photograph of her face and showed NW the extent of her injuries. After this, NW agreed to be taken to hospital where she received treatment.45
Officer Burtnyk served the FVRO on Mr Walkerbear at 5.35 pm on 29 July 2021 and at the same time, he explained the terms of the FVRO to Mr Walkerbear. Nevertheless, between 1 and 13 August 2021, NW reported that Mr Walkerbear had breached the FVRO on three occasions, and he was subsequently charged with two offences in relation to these alleged breaches.51,52,53
At NW’s request, the FVRO was revoked by the Magistrates Court at Kununurra on 19 August 2021. NW told the court that she was intending to leave Mr Walkerbear, and relocate to the Northern Territory. However, as will become clear, she did not do so and in fact she and Mr Walkerbear remained together as a couple.54,55,56
I am aware of research studies which have shown that it can take a significant number of domestic and family violence incidents before victims feel able to leave their violent partners. At the inquest, Officer Hugo (the OIC of the Police’s Family Violence Division), agreed that the reasons why victims may find it difficult to leave perpetrators of domestic and family violence may be complex and multi-factorial, and can include emotional, psychological, and cultural issues; access to employment; the availability of alternative stable housing; and financial and other concerns.57
In passing, I note that at the inquest, Officer Hugo noted that since January 2022 it has been mandatory for police officers attending a suspected family violence incident to activate their body worn cameras. In this case, all of the attending officers did so when they visited properties at 4B Carbeen Street, and 67A Barringtonia Avenue respectively.58 51 Exhibit 1, Vol 2, Tab 43, Statement - Sen. Const. S Burtnyk (03.04.23), paras 3-15 and ts 29.10. 24 (Burtnyk), pp36-37 52 Exhibit 1, Vol 2, Tab 59, Statement - FC Const. R Morrisey (11.05.23) 53 Exhibit 1, Vol 1, Tab 6, IAU Report – Det. A’Sen. Sgt. D Mackay (26.02.24), p9 54 Exhibit 1, Vol 2, Tab 59, Statement - FC Const. R Morrisey (11.05.23) 55 Exhibit 1, Vol 2, Tab 28, Transcript of proceedings - Magistrates Court at Kununurra (19.08.21) 56 Exhibit 1, Vol 2, Tab 29, NW’s FVRO records - Magistrates Court at Kununurra 57 ts 30.10.24 (Hugo), pp122-123 & 131-132 58 ts 30.10.24 (Hugo), pp124-125
[2024] WACOR 51 EVENTS LEADING TO NW’s DEATH59,60 NW’s mother’s call for assistance61,62,63,64,65,66,67,68,69
During the evening of Saturday, 9 October 2021 NW and Mr Walkerbear were drinking alcohol and socialising with friends and family members at a house in Kununurra. At some point during the night, Mr Walkerbear told NW it was time to leave, and he began yelling at her. Some of the people at the house confronted Mr Walkerbear about his behaviour towards NW, and a physical altercation broke out.
Meanwhile, NW spoke to her mother and said she was fearful of leaving the house alone with Mr Walkerbear. NW asked her mother to accompany them, which the mother agreed to do. NW, her mother and Mr Walkerbear left the house and walked to a property at 4B Carbeen Street in Kununurra, where NW and Mr Walkerbear sat on the driveway.
A short time later, NW’s mother left the 4B Carbeen Street address, and at 9.46 pm, she called emergency services. NW’s mother asked the emergency operator to arrange for police to go to 4B Carbeen Street and take NW to a women’s refuge.
NW’s mother told the emergency services operator that she was worried that NW was going to be assaulted by Mr Walkerbear that evening. NW’s mother also said that Mr Walkerbear was “an aggressive man” who had been drinking, and that it wasn’t safe for her daughter to be in the house.70
The Police Operations Centre (POC) in Perth created a family violence incident Computer Aided Dispatch task (CAD Task 1), and requested police at Kununurra to assist.71 59 Exhibit 1, Vol 1, Tab 6, IAU Report - Det. A’Sen. Sgt. D Mackay (26.02.24), pp4-93 60 Exhibit 1, Vol 2, Tab 1, Homicide Squad Report - Det. Sgt. M Long (04.01.24) 61 Exhibit 1, Vol 1, Tabs 10 & 10.1, Statements - NW’s mother (22.10.21 & 28.10.21) 62 Exhibit 1, Vol 2, Tab 63, Statement - Prob. Const. C Piahana (03.12.21), paras 1-53 and ts 29.10. 24 (Piahana), pp9-31 63 Exhibit 1, Vol 2, Tab 42, Statement - Sen. Const. S Burtnyk (02.11.21), paras 1-33 and ts 29.10. 24 (Burtnyk), pp31-48 64 Exhibit 1, Vol 2, Tab 53, Statement - Ms C Johnson (23.10.21) 65 Exhibit 1, Vol 2, Tab 61, Statement - Ms E Nipper (22.10.21) 66 Exhibit 1, Vol 2, Tab 65, Statement - Ms C Rosewood (23.10.21) 67 Exhibit 1, Vol 2, Tabs 66 & 67, Statements - Ms G Rosewood (27.10.21 & 20.06.23) 68 Exhibit 1, Vol 2, Tabs 68 & 69, Statements - Mr P Rosewood (02.11.21 & 20.06.23) 69 Exhibit 1, Vol 2, Tab 73, Statement - Mr B Waterloo (26.10.21) 70 Exhibit 1, Vol 1, Tab 7, Incident Report LWP21100900765810 (9.46 pm, 09.10.21 - CAD Task 1) 71 ts 30.10.24 (Glasson), pp94-95
At the relevant time, Officer Glasson was an acting sergeant and was occupying the position of Kununurra police station supervisor.72 This was clearly a demanding and busy position, and as the Internal Affairs unit (IAU) investigation report noted: To fulfil the role of Kununurra Police Station supervisor, you have to be CAD control supervisor, police station lock-up supervisor, prosecution system reviewer and approver, IMS incident reporter, reviewer and finaliser, attend to administrative duties, including telephone and responding to front counter inquiries, and attending to Kununurra Police Station human resource issues.73,74
Officer Glasson allocated CAD Task 1 to Officer Burtnyk and Officer Piahana at 9.56 pm. At that time, Officer Piahana was a probationary constable and she had been in Kununurra for three months. Her partner, Officer Burtnyk, was a first class constable and he had been a police officer for about eight years.75
Officer Burtnyk and Officer Piahana arrived at 4B Carbeen Street at about 10.05 pm. Officer Burtnyk was driving the police vehicle, and as passenger, Officer Piahana said it was likely that on the way she had read out the text of the CAD Task 1, which was as follows: CLR (i.e.: caller) is requesting police to go to A/A (i.e.: above address) and take her daughter (NW) to a shelter. CLR states that she has just left A/A and her daughter stated that she is going to get bashed tonight by her partner Walkerbear, Warwick. CLR states that Walkerbear is an aggressive man and has been drinking today - not safe for her daughter to be in the house. Nil children at A/A.76,77
After the officers arrived at 4B Carbeen Street, Officer Piahana knocked on the front door while Officer Burtnyk shone his torch down the left hand side of the property. No one was visible, and the front door was opened by Ms Doneta Nipper.
72 ts 30.10.24 (Glasson), pp91-92 73 Exhibit 1, Vol 1, Tab 6, IAU Report - Det. A’Sen. Sgt. D Mackay (26.02.24), p84 74 ts 30.10.24 (Glasson), pp91-92 75 ts 29.10.24 (Piahana), p9 and ts 29.10.24 (Burtnyk), p32 76 Exhibit 1, Vol 1, Tab 7, Incident Report LWP21100900765810 (9.46 pm, 09.10.21 - CAD Task 1) 77 See also: ts 29.10.24 (Piahana), pp12-13
Officer Piahana asked Ms Nipper if someone had called police, and Ms Nipper said “No”, and she (Ms Nipper) confirmed that neither Mr Walkerbear, NW, or NW’s mother lived at her house. Ms Nipper also told police Mr Walkerbear and NW lived in a house at the end of Barringtonia Avenue.
At the inquest, Officer Piahana said that she recognised the property described by Ms Nipper as 67A Barringtonia Avenue, because she had attended a previous task at that address relating to a member of NW’s family.78
Although neither Officer Piahana nor Officer Burtnyk had had any previous dealings with NW, NW’s mother, or Mr Walkerbear, during their interaction with Ms Nipper, neither of the officers asked any questions about NW’s location or welfare. At the inquest, both Officer Piahana and Officer Burtnyk agreed that with the benefit of hindsight, they should have made more fulsome enquiries with Ms Nipper about NW’s location and the nature of her relationship with Mr Walkerbear before leaving 4B Carbeen Street.79
In any case, although Officers Burtnyk and Piahana had intended to go straight to 67A Barringtonia Avenue to locate NW and Mr Walkerbear, they were unable to do so. That is because at 10.09 pm, just as they were leaving the Carbeen Street address, the officers were allocated an unrelated, but higher priority task. This task (CAD Task 2) required the officers to proceed urgently to an address in Kununurra to assist a victim of family violence.80
Once Officer Glasson had allocated CAD Task 2 to Officers Burtnyk and Piahana, they were “released” from CAD Task 1. When the officers arrived at the CAD Task 2 address, they were required to arrange for a woman to be taken to hospital, and their subsequent enquiries took several hours.
78 ts 29.10.24 (Piahana), p18 79 ts 29.10.24 (Piahana), pp13-17 and ts 29.10.24 (Burtnyk), pp38-39 80 Exhibit 1, Vol 1, Tab 7.1, Incident Report LWP21100900765891 (10.04 pm, 09.10.21 - CAD Task 2)
As a result of being allocated CAD Task 2, Officers Burtnyk and Piahana made no further attempts to locate NW that night. Prior to leaving 4B Carbeen Street, Officer Piahana did not enter an “at scene” time in the text for CAD Task 1, which would have been her responsibility given she was the passenger in the police vehicle.
Further, neither officer subsequently entered an update into the text for CAD Task 1 recording their enquiries at 4B Carbeen Street, and their plan to visit 67A Barringtonia Avenue to try to locate NW and Mr Walkerbear, nor did they provide Officer Glasson with a verbal update using their police radios.
It appears that these failures by Officers Burtnyk and Piahana were partly due to the urgency associated with CAD Task 2, and also to communications issues with OneForce, the application on police-issued mobile phones used to manage assigned CAD tasks. As I will explain later in this finding, at the relevant time communication issues with OneForce were routine in Kununurra, and these issues significantly increased the difficulties officers faced in conducting routine patrols.81
At the inquest, Officer Glasson agreed that it would have been best practice for him to have asked if Officer Piahana and Officer Burtnyk had attended 4B Carbeen Street, and the result of their enquiries. His explanation for not doing so at the time was that he needed the officers to attend CAD Task 2, which was of higher priority. Officer Glasson also said: I didn’t ask for (a) briefing. I knew we would eventually get back to that job (i.e.: CAD Task 1), so I wouldn’t have worried about it then.
But priorities change and I just – yes.82
81 ts 29.10.24 (Burtnyk), pp34-35 & 40 82 ts 30.10.24 (Glasson), p95
[2024] WACOR 51 Ms Nipper’s call for assistance83,84,85
At 10.21 pm, Ms Nipper called emergency services to advise there was a “girl quietly sobbing” in her backyard at 4B Carbeen Street. In her police statements, Ms Nipper says it was dark when she looked out of her bedroom window at the back of her house into the backyard and that she “couldn’t see anyone”. Nevertheless, Ms Nipper says she could hear a man “talking quietly”, who she recognised as Mr Walkerbear.86,87
In her statement, Ms Nipper also says “I assumed the girl was (NW), his partner”, and that she called out to Mr Walkerbear: “Warrick, you had better stop as I had rung the Police already”. Ms Nipper says she told the emergency services operator that the Police were looking for NW and Mr Walkerbear, and “they were now in the back yard”.88,89
Ms Nipper says there is no light in her backyard, “only one around the left side near the laundry door”. As she waited for police to attend, Ms Nipper says she “put the light on and went into the backyard”, but that Mr Walkerbear and NW had gone. Ms Nipper says she then went back to bed, and that when she went into the backyard again she: “didn’t see any blood or anything strange”.90,91
The transcript of Ms Nipper’s emergency services call confirms that she told the emergency services operator that her address was 4B Carbeen Street, and that she also said: You guys came earlier on…there is a fight out the back here...Yeah with (NW) and (Mr Walkerbear)…they came around early on looking for them…I think she (i.e.: NW’s mother) rang early on and cops came around and I said no one was here, but then I went to the toilet and heard noise in the backyard. I think they’re out the back here fighting…I can hear her crying.92 83 Exhibit 1, Vol 1, Tab 6, IAU Report - Det. A’Sen. Sgt. D Mackay (26.02.24) 84 Exhibit 1, Vol 1, Tab 7.1, Incident Report LWP21100900765891 (10.04 pm, 09.10.21 - CAD Task 2) 85 Exhibit 1, Vol 1, Tabs 11 & 11.1, Statements - Ms D Nipper (22.10.21 & 28.10.21) 86 Exhibit 1, Vol 1, Tab 11, Statement - Ms D Nipper (22.10.21), paras 18-28 87 Exhibit 1, Vol 1, Tab 11.1, Statement - Ms D Nipper (28.10.21), paras 27-38 88 Exhibit 1, Vol 1, Tab 11, Statement - Ms D Nipper (22.10.21), paras 29-34 89 Exhibit 1, Vol 1, Tab 11.1, Statement - Ms D Nipper (28.10.21), paras 39-46 90 Exhibit 1, Vol 1, Tab 11, Statement - Ms D Nipper (22.10.21), paras 35-39 91 Exhibit 1, Vol 1, Tab 11.1, Statement - Ms D Nipper (28.10.21), paras 49-55 92 Exhibit 1, Vol 1, Tab 6, IAU Report - Det. A’Sen. Sgt. D Mackay (26.02.24), pp49-50
The emergency services operator told Ms Nipper that police would attend, and the information Ms Nipper had provided was added to the text of CAD Task 1 by the Police Operations Centre in Perth.93,94 However, at the inquest, Officer Glasson confirmed that he was unaware of this update to CAD Task 1.
Although Officer Glasson was supervising CAD tasks, he was also responsible for his other duties as station supervisor. It appears that Officer Glasson did not become aware of the update to CAD Task 1 partly because of his busy workload, and also because at the time he was unaware of a system feature which showed that an update had been made. At the inquest, Officer Glasson said: I’ve since learnt that there’s a – a little tiny arrow at the side of the bar that lights up, but if you’re not looking for it, you – you don’t hear it or see it all.95
As a result, there was no immediate police response to Ms Nipper’s call, although at the relevant time Officer Glasson would not have had an available police vehicle to dispatch, because both were busy.96
Whilst it is not entirely clear that the woman Ms Nipper heard sobbing in her backyard was NW, nevertheless, Ms Nipper assumed it was because she recognised Mr Walkerbear’s voice (although he was talking softly) and knew NW was in a relationship with him. If police had attended 4B Carbeen Street soon after Ms Nipper’s call, there is at least a possibility that they might have located NW, and been able to speak with her about what had been going on between her and Mr Walkerbear.
Of course, it is impossible to know whether or not NW would have accepted help from police if she had been found. I make that observation on the basis that after she was seriously assaulted by Mr Walkerbear in July 2021, NW was very reluctant to seek medical treatment, and declined to provide a statement to police confirming the details of the assault.97 93 See also: Exhibit 1, Vol 1, Tab 7, Incident Report LWP21100900765810 (9.46 pm, 09.10.21 - CAD Task 1) 94 ts 30.10.24 (Glasson), p97 95 ts 30.10.24 (Glasson), p97 96 ts 30.10.24 (Glasson), p99 97 Exhibit 1, Vol 2, Tab 71, Statement - FC Const. L Tompkins (27.11.21), para 42 and ts 29.10. 24 (Tompkins), p78
[2024] WACOR 51 CAD Task 1 is reassigned98,99,100,101
At 11.37 pm, Officer Glasson realised that CAD Task 1 was still open, and he reassigned it to Officers Tompkins and Lee (in police vehicle EK101), who had completed their previous task. At the relevant time, there was usually only one police vehicle patrolling Kununurra during the hours of darkness, however during shift changeovers two vehicles were sometimes available for periods of time.102
As a result of the ongoing communication issues being experienced with OneForce in Kununurra, Officer Glasson used the police radio to make the following broadcast when he reassigned CAD Task 1 to Officers Tompkins and Lee: “There’s a 329 (i.e.: a domestic violence incident) at 4B Carbeen Street if you are free”.103 Officer Piahana (in police vehicle EK103) heard this broadcast, and made the following transmission in response: (Officer Burtnyk) and I went to that address (i.e. 4B Carbeen Street) and no one that was mentioned in that CAD text was there. The occupier (i.e.: Ms Nipper) said to try (NW’s mother’s) house…at I believe 67A Barringtonia I was unable to throw the update on due to the P2 (i.e.: CAD Task 2).104,105
During her broadcast, Officer Piahana did not state (nor was she asked) what time she and Officer Burtnyk had attended 4B Carbeen Street earlier that night. Further, as I have already noted, an “at scene” had not been logged against CAD Task 1 for that attendance.
At the inquest, Officer Piahana accepted that with the benefit of hindsight she ought to have communicated the time that she and Officer Burtnyk had attended 4B Carbeen Street,106 and in my view this is an appropriate concession. This information would clearly have been relevant to Officers 98 Exhibit 1, Vol 1, Tab 6, IAU Report - Det. A’Sen. Sgt. D Mackay (26.02.24) 99 Exhibit 1, Vol 2, Tab 63, Statement - Prob. Const. C Piahana (03.12.21), paras 54-59 and ts 29.10. 24 (Piahana), pp21-22 100 Exhibit 1, Vol 2, Tab 56, Statement - FC Const. D Lee (15.03.23), paras 2-26 and ts 29.10. 24 (Lee), pp49-71 101 Exhibit 1, Vol 2, Tab 71, Statement - FC Const. L Tompkins (27.11.21), paras 46-65 and ts 29.10.24 (Tompkins), pp71-85 102 ts 29.10.24 (Burtnyk), p44 and ts 29.10.24 (Lee), p50 103 Exhibit 1, Vol 1, Tab 6, IAU Report - Det. A’Sen. Sgt. D Mackay (26.02.24), p54 104 ts 29.10.24 (Piahana), p21 105 Exhibit 1, Vol 1, Tab 6, IAU Report - Det. A’Sen. Sgt. D Mackay (26.02.24), p55 106 ts 29.10.24 (Piahana), p22, and see also: ts 30.10.24 (Glasson), p102 where Officer Glasson agrees
[2024] WACOR 51 Tompkins and Lee in their assessment of the priority that should have been attached to the task of locating NW.
At the inquest, Officer Glasson said if he had been aware of Ms Nipper’s earlier call at 10.21 pm (suggesting that NW and Mr Walkerbear were at 4B Carbeen Street), he would have ensured Officers Lee and Tompkins went there, instead of 67A Barringtonia, and that in his view, this was “the sliding door moment”.107
In any case, following Officer Piahana’s transmission, Officers Tompkins and Lee went to 67A Barringtonia Avenue, and they arrived at the premises at 11.42 pm. Officer Lee knocked on the front door of the home, but there was no response. There was also no reply when Officer Lee shone his torch into the backyard of the property and called out “Hello, Police”.
Meanwhile, Officer Tompkins had gone to the front bedroom of the house, where she knew NW slept from previous visits to the premises. As Officer Tompkins looked through a small gap in the window, she saw a mattress on the floor, but there was no one in the bedroom, and she heard no noise or movements from within the house. The scene was dark and quiet, and in her police statement, Officer Tompkins said she did not believe the house was occupied at the time.108
After briefly checking the surrounding area, Officers Tompkins and Lee left the scene, and Officer Tompkins used EK101’s police radio to update Officer Glasson about their enquiries.109
At the inquest, Officer Tompkins and Officer Lee each confirmed that they had not checked the text of CAD Task 1, and were therefore unaware of Ms Nipper’s call at 10.21 pm about the possible sighting of NW and Mr Walkerbear at 4B Carbeen Street. Officer Tompkins and Officer Lee also agreed they should have checked the text of CAD Task 1, and had 107 ts 30.10.24 (Glasson), pp99-103 108 Exhibit 1, Vol 2, Tab 71, Statement - FC Const. L Tompkins (27.11.21), paras 64-68 109 Exhibit 1, Vol 2, Tab 56, Statement - FC Const. D Lee (15.03.23), paras 11-24
[2024] WACOR 51 they been aware of Ms Nipper’s call, they would have approached the task of locating NW with a greater sense of urgency.110
Officer Glasson also noted that police had also attended 67A Barringtonia Avenue, but that no one was home.111
At 11.48 pm, Officer Glasson “closed” CAD Task 1, after adding the following text to this job: [NW] has made no formal complaint to police. There are no VROs in place between [Mr Walkerbear] and [NW]. Police have attended two addresses with no luck. Task to be closed pending any formal complaint or request for assistance from NW.112
At the time he closed CAD Task 1, Officer Glasson was unaware of Ms Nipper’s call at 10.21 pm, and therefore the possibility that NW and Mr Walkerbear had in fact been at 4B Carbeen Street at around that time.
It also appears that Officer Glasson was unaware of NW’s previous FVRO, or that Mr Walkerbear had been charged with breaching it.113 After CAD Task 1 was closed, no further attempts were made to locate NW or Mr Walkerbear.
Officer Glasson also said that with the benefit of hindsight he would not have closed CAD Task 1, and that since NW’s death, his general practice has changed.115
At the inquest, Officer Hugo confirmed current police practice is that a CAD task cannot be closed by a Sergeant (or acting Sergeant) without the parties being located and spoke to. Officer Hugo also noted that: So as part of our investigative doctrine, when we’re doing an investigation of family violence, we need to sight both parties...and so the CAD jobs will remain open. If they’ve spoken to, for example, one of the parties, they may close the CAD job because they’ve conducted inquiries. So there’s still that need to speak to the second party. It might be the fact that I’ve spoken to the victim that has called. The perpetrator has decamped the scene. So then we would conduct our family violence investigation.116
After listening carefully to the evidence of attending police and their supervisor at the inquest, it is clear that they have each reflected deeply on their involvement in the suspected domestic violence incident involving NW. This is to their great credit.
At the inquest, Officer Tompkins said she had been deeply affected by NW’s death, and that with the benefit of hindsight she would have questioned the decision to close CAD Task 1, and ensured that the investigation into NW’s whereabouts and welfare continued. Officer Tompkins also said: I would have questioned the decision to close the job, knowing what I know now. I would have spoken up and ensured the investigation continued as hindsight we had sufficient information to suggest a family violence incident was about to occur. I would have made contact with (NW’s mother) and obtained more information and details.
I would have made contact with (EK 103) and made sure I had a full understanding of the task. I would have continued throughout the night to look for NW and made sure she was safe. I would have conducted a more thorough investigation. At the time I didn’t realise what I was 115 ts 30.10.24 (Glasson), pp104-105 116 ts 30.10.24 (Hugo), p125
[2024] WACOR 51 doing wasn’t enough, but I know now that I could have done more.
Hearing the ‘000’ update from (Ms Nipper) during my internal investigation was quite upsetting, because it would have raised my concern and suggested where NW was.117 Request for an ambulance118,119,120,121
At 4.27 am on 10 October 2021, St John Ambulance (SJA) officers requested police assistance after a male caller had called emergency services asking for an ambulance because an adult female had fallen over and “busted her lip”.122 Subsequent police enquiries established that the male caller was Mr Walkerbear, who had used his brother’s mobile phone to make the call, but this was not appreciated at the time.123
Given what is known about the timeline of relevant events, it seems likely that Mr Walkerbear made his call requesting an ambulance sometime after he had assaulted NW. In any case, Officer Glasson created a CAD task for the SJA request, which he assigned to Officers Burtnyk and Piahana.
The officers attended the task address namely Unit 4, 13 Carbeen Street, at 4.36 am but no one was home.
A short time later an ambulance arrived, and Officers Burtnyk and Piahana had a brief discussion with the ambulance officers. They mentioned their earlier attendance at 4B Carbeen Street, and suggested they all go there to check if anyone needed assistance. It appears that Officers Burtnyk and Piahana suspected this task may be related to CAD Task 1 because of the proximity of the task addresses on Carbeen Street.
Officers Burtnyk and Piahana and the ambulance officers arrived at 4B Carbeen Street at 4.41 am. The scene was quiet, and the officers checked down the side of the property (which was clear) before knocking on the front door and speaking with Mr Kingsley Nipper. Mr Nipper confirmed no one had called police or an ambulance, and there was no one at the address who was injured.
117 ts 29.10.24 (Tompkins), p81 118 Exhibit 1, Vol 1, Tab 7.2, Incident Report LWP211000007667770 (4.27 am, 10.10.21) 119 Exhibit 1, Vol 2, Tab 42, Statement - Sen. Const. S Burtnyk (02.11.21), paras 35-62 and ts 29.10. 24 (Burtnyk), pp41 120 Exhibit 1, Vol 2, Tab 63, Statement - Prob. Const. C Piahana (03.12.21), paras 60-96 and ts 29.10. 24 (Piahana), pp23-27 121 Exhibit 1, Vol 2, Tabs 33 & 34, SJA Card Viewer & Patient Not Transported form (10.10.21) 122 Exhibit 1, Vol 1, Tab 6, IAU Report - Det. A’Sen. Sgt. D Mackay (26.02.24), pp50-53 123 Exhibit 1, Vol 1, Tab 12, Statement, Mr Z Thomas (30.10.21)
NW’s remains are located124,125,126,127,128,129,130,131,132,133,134,135
On 18 October 2021, NW’s mother contacted police to advise that she had not seen NW for about two weeks. Police commenced their inquiries, and a missing person incident report was created on 21 October 2021 in response to concerns for NW’s welfare.136
When police interviewed Mr Walkerbear on 23 October 2021, he initially claimed that he and NW had broken up after she walked off from 4B Carbeen Street, and that he had not seen her since. However, Mr Walkerbear also told police he had seen NW twice in Kununurra since her disappearance.137,138
Of course none of these statements by Mr Walkerbear were true. By the time of Mr Walkerbear’s interview with police, NW had been dead for almost two weeks.
On 24 October 2021, community members discovered NW’s body in a shallow grave in bushland in the vicinity of Acacia Court, in Kununurra.
Police were alerted, and NW’s remains were recovered and transported to the State Mortuary in Perth.139 124 Exhibit 1, Vol 1, Tab 8, Incident Report 21102021 1015 13592 (21.10.21) 125 Exhibit 1, Vol 1, Tabs 8.1 & 19, Incident Report 24102021 1600 12917 (24.10.21) 126 Exhibit 1, Vol 1, Tab 6, IAU Report - Det. A’Sen. Sgt. D Mackay (26.02.24) 127 Exhibit 1, Vol 1, Tabs 10 & 10.1, Statements - NW’s mother (22.10.21 & 28.10.21) 128 Exhibit 1, Vol 2, Tab 41, Statement - Ms J Bradshaw (25.10.21) 129 Exhibit 1, Vol 2, Tab 48, Statement - Mr J Drill (25.10.21) 130 Exhibit 1, Vol 2, Tab 49, Statement - Ms K Ellis (11.04.23) 131 Exhibit 1, Vol 2, Tab 50, Statement - Ms Y Galbat (24.10.21) 132 Exhibit 1, Vol 2, Tab 54, Statement - FC Const. D Lee (29.11.21), paras 3-28 133 Exhibit 1, Vol 2, Tab 58, Statement - Ms R Macey (01.12.21) 134 Exhibit 1, Vol 2, Tab 62, Statement - Mr M Ogilvie (25.10.21), paras 3-28 135 Exhibit 1, Vol 2, Tabs 71 & 72, Statements - FC Const. M Tompkins (27.11.21 & 19.07.22) 136 Exhibit 1, Vol 2, Tab 4, At Risk Person Assessment - Missing Person form 137 Exhibit 1, Vol 2, Tab 30, Map depicting the location of NW’s body 138 Exhibit 1, Vol 1, Tab 23, [2023] WASCSR 33, Sentencing remarks per Quinlan, CJ (17.11.23) 139 Exhibit 1, Vol 2, Tab 30, Map depicting the location of NW’s body
Two forensic pathologists (Dr N Vagaja and Dr K Patton), and a forensic anthropologist (Dr A Buck) carried out post mortem examinations of NW’s remains at the State Mortuary on 29 October 2021, 1 November 2021, and 8 November 2021.140,141
NW’s remains were also examined by two doctors from the Sexual Assault Resource Centre (Dr M Kelly and Dr K Farrington) on 29 October
In her report, Dr Kelly said: I can neither confirm nor exclude that (NW) had experienced vaginal and/or anal penetration (consensual or non-consensual) prior to or after death as this may occur with no or minimal injury”.142,143
The post mortem examination by Dr Vagaja, Dr Patton, and Dr Buck noted established post mortem changes, and that “most of the internal organs and tissues were lost to decomposition”. There were “multiple bilateral rib fractures of varying ages”, some of which appeared to be recent, and a “partly healed fracture of the cartilage at the front of the neck (thyroid cartilage)”.144,145
Microscopic examination of tissues confirmed these findings, but toxicological analysis was not undertaken because of the state of NW’s remains.146,147
Following their post mortem examination, Dr Vagaja, Dr Patton, and Dr Buck were unable to ascertain the cause of NW’s death. It follows that I have been unable to make any finding as to the cause of NW’s death.
However, as Mr Walkerbear was convicted of NW’s manslaughter, I find that NW’s death occurred by way of unlawful homicide.148 140 Exhibit 1, Vol 1, Tab 4, Supplementary Post Mortem Report (07.02.23) 141 Exhibit 1, Vol 1, Tab 4.1, Post Mortem Report (08.11.21) 142 Exhibit 1, Vol 2, Tab 31, SARC Forensic Biology Specimens form (29.10.21) 143 Exhibit 1, Vol 2, Tab 32, SARC Medical Report - Dr M Kelly (01.11.21) 144 Exhibit 1, Vol 1, Tab 4, Supplementary Post Mortem Report (07.02.23) 145 Exhibit 1, Vol 1, Tab 4.1, Post Mortem Report (08.11.21) 146 Exhibit 1, Vol 1, Tab 4, Supplementary Post Mortem Report (07.02.23) 147 Exhibit 1, Vol 1, Tab 4.1, Post Mortem Report (08.11.21) 148 Exhibit 1, Vol 1, Tab 23, [2023] WASCSR 33, Sentencing remarks per Quinlan, CJ (17.11.23)
[2024] WACOR 51 ISSUES ARISING FROM THE EVIDENCE OneForce communication issues149
As noted, OneForce is the application police use on their issued mobile phones to manage CAD tasks they are assigned. The application depends on a reliable network connection, and at the relevant time in Kununurra this was often not available.150,151,152
At the inquest, Officer Burtnyk said there were “daily issues” with OneForce in Kununurra at the relevant time, noting that: We constantly have to change between 4G and 3G depending on how the service was or where we were…positioned in the town. So…if we wanted to like look up photos or anything like that, we wouldn’t be able to do that on 3G. So…if we wanted to look up jobs and make sure the jobs are running a little bit smoother, we would change it to 3G so…they’re not trying to download photos…you know, people’s images when we go to jobs. Sometimes it just wouldn’t even load. So the 3G service was easier so we could just manage the general text of the jobs.153
Adding to the frustration for officers in Kununurra using OneForce, was the fact that at times the application would “crash” and stop working altogether. In this situation, the only option was to log out of the application and log back in, which would take time. Officer Burtnyk also confirmed that there were situations where it was necessary for officers to use the police radio to provide updates to CAD tasks, when OneForce failed to function correctly.154
In a report he prepared for the Court, Mr Marc Smith (Chief Technology Officer) outlined the steps the Police have taken to “improve deficiencies in the use of OneForce mobile phones in regional areas of the State”.155 149 Exhibit 1, Vol 2, Tab 75, Report: Improvement of the use of OneForce mobile phones in regional areas (17.10.24) 150 See for example: Exhibit 1, Vol 2, Tab 56, Statement - FC Const. D Lee (15.03.23), paras 8-10 151 ts 29.10. 24 (Tompkins), pp75-76 and ts 30.10. 24 (Glasson), p109 152 See also: ts 30.10. 24 (Mackay), pp111-112 & 114 153 ts 29.10. 24 (Burtnyk), p34 154 ts 29.10. 24 (Burtnyk), pp34-35 155 Exhibit 1, Vol 2, Tab 75, Report: Improvement of the use of OneForce mobile phones in regional areas (17.10.24)
In his report, Mr Smith noted that recent developments in Low Earth Orbit satellites (LEO) have meant that high speed satellite based internet services can be made available to police officers operating in remote areas of the State. Mr Smith also said: The WA Police Force Anywhere Communications Project is implementing a unified communication platform on 550 police vehicles (which largely comprises the WA Police Force's regional fleet and part of its specialised fleet that may be deployed regionally) and at 121 remote facilities across regional WA. “Unified” means the integration of the Starlink LEO satellite system, 4G, and the fibre/copper terrestrial network system to deliver more resilient and reliable communications.156
In terms of the timeframe for deploying and fitting the equipment necessary to access the Starlink LEO satellite system, Mr Smith’s report noted that the deployment to remote police stations started in June 2024, and the target date for completion of the work is June 2025. As for the equipment being fitted to police vehicles, Mr Smith said: “It is anticipated that circa 180 vehicles will be fitted by June 2025 with the targeted completion of all 550 vehicles in June 2026”.157
At the inquest, Officer Piahana (who is now based in a regional centre in the south of the State) said that one of the police vehicles at her station had been fitted with the Starlink system. Ms Paljetak asked Officer Piahana about her experience of using the Starlink system, and she (Officer Piahana) said: “I haven’t used it too much, but I have used it and it has been a lot more reliable than operating off a…network”.158
On the basis of the available evidence, I am satisfied that the improvements to the connectivity of the OneForce application which are currently underway are appropriate. However, I would strongly urge the Police to take whatever steps are necessary to expedite the roll out of the Starlink system.
156 Exhibit 1, Vol 2, Tab 75, Report: Improvement of the use of OneForce mobile phones in regional areas (17.10.24), p2 157 Exhibit 1, Vol 2, Tab 75, Report: Improvement of the use of OneForce mobile phones in regional areas (17.10.24), p4 158 ts 29.10. 24 (Piahana), p30
[2024] WACOR 51 Domestic and family violence training159,160
At the inquest, Officer Hugo outlined the improvements that the Family Violence Division (FVD) have made to family and domestic violence response training. Officer Hugo explained that in 2023, she implemented the family violence training and assessment strategy, which had been based on a review of the recommendations of several Royal Commissions and inquests, as well as national training guidelines.
Once the strategy had been developed, five levels of training were identified, with training specifically aimed at customer service operators, police cadets, auxiliary officers, recruits, and constables at all grades, sergeants, senior sergeants, and inspectors. Officer Hugo also explained that FVD had partnered with experts and developed a face-to-face learning event intended to: [A]ssist frontline officers and supervisors to make more informed decisions in the context of the complexities of family violence. It is intended that officers will gain skills in initial attendance and response, identifying the primary aggressor, coercion and control, the legislative requirements for protective orders and a deeper understanding of agency expectation.161
Since then, 17 learning events have been conducted in metropolitan and regional areas, with regional events including outreach to remote staff by way of a video-link.
In relation to the issue of cultural shaming, which can be a powerful factor in influencing some victims of family and domestic violence to remain with their partners, Officer Hugo noted that: So we’ve included in our training and on our online training a significant part about cultural shaming, and it’s not just for Aboriginal and Torres Strait Islander people but also for CALD (i.e.: culturally and linguistically diverse) communities because we know that CALD communities are heavily underreported in family violence as well. So we’ve done significant work liaising with our Aboriginal Affairs Division as well as our Community Engagement Division, who specialise in CALD communities, to really make sure…that we are really incorporating the whole community in this training.165
In addition to the roll out of the face-to-face training I have referred to, Officer Hugo also noted that the FVD has developed information for victims of family or domestic violence. This useful information is presented in the format of a small, folded card designed to fit in a wallet or purse. The card includes information about family and domestic violence, along with the telephone numbers of relevant agencies and services, and a QR code which makes the information available in 20 languages, including eight Aboriginal languages, and Auslan.166,167
Officer Hugo also advised that the FVD had developed a succinct Supervisor Review Checklist for use by officers supervising the police response to a domestic or family violence incident. The previous checklist was three pages long, and had proved inefficient, leading to officers developing their own hybrid versions.168,169
In my view, use of the checklist has considerable benefit, and I have recommended that the Police consider making it mandatory for officers supervising CAD tasks involving domestic and family violence to use the Supervisor Review Checklist FVD developed.
165 ts 30.10.24 (Hugo), p118 166 Exhibit 1, Vol 2, Tab 76.8, Family Violence Information and Support card 167 ts 30.10.24 (Hugo), pp126-128 168 Exhibit 1, Vol 2, Tab 76.6, Supervisor Checklist for FVI 169 ts 30.10.24 (Hugo), p125
[2024] WACOR 51 ASSESSMENT OF POLICE CONDUCT Relevant considerations170,171
I now turn to assess the conduct of Officers Piahana, Burtnyk, Lee, Tomkins, and Glasson (the Officers) who were involved in responding to or managing the suspected domestic violence incident involving NW. I have had regard to the Briginshaw test when deciding whether to make adverse findings about any of the Officers.
I acknowledge police officers perform a challenging and difficult job, and that they are routinely subjected to verbal (and sometimes physical) abuse.
I also accept that at the relevant time, the workload for police stationed at Kununurra was heavy, and there were connectivity issues with the OneForce application used by police on their mobile phones.172
As I have noted, the role of Kununurra police station supervisor, which was occupied by Officer Glasson at the relevant time, was clearly very demanding. Further, the police workload in Kununurra at the time was heavy.
At the inquest, Officer Burtnyk said that in his opinion at the relevant time, Kununurra was “a very, very, very, very busy station”. Officer Burtnyk also said and it was not uncommon for him to “change partners multiple times in the night just to go to deal with the jobs” and that these were “the pressures that we would constantly face”.173
Finally, I note that at the relevant time, all of the Officers had completed a national domestic and family violence training course. At the inquest each of the Officers accepted that a police officer is required to investigate all reports of domestic and family violence to determine if an offence is about to be committed, has been committed, or will be committed. Each of the Officers also accepted that this requirement is enshrined in legislation and relevant Police policies.174,175 170 Exhibit 1, Vol 1, Tab 6, IAU Report - Det. A’Sen. Sgt. D Mackay 171 Exhibit 1, Vol 2, Tab 74, Family Violence Division Review of NW’s death (30.12.21) 172 See for example: ts 29.10. 24 (Burtnyk), p34 173 ts 29.10.24 (Burtnyk), p43 174 ts 29.10.24 (Piahana), p11, ts 29.10.24 (Burtnyk), pp32-33 and ts 29.10.24 (Tompkins), p73 175 ts 29.10.24 (Lee), pp49-50 and ts 30.10.24 (Glasson), pp89-90
[2024] WACOR 51 IAU report findings176,177
On 26 October 2021, Homicide Squad detectives investigating NW’s death, advised the Internal Affairs unit (IAU) that their investigation had: [I]dentified the limited enquiries conducted by the officers attached to EK103 and EK101 in relation to the three “000” calls made between 9 - 10 October 2021, which resulted in (NW) not being located, proved to be fatal.178
As a result of the Homicide Squad referral, Detective Acting Senior Sergeant Mackay (Officer Mackay) conducted an IAU investigation, and his comprehensive report was part of the brief of evidence before the Court.179 Officer Mackay said that in his opinion, “no criminal offences were identified during the course of this IAU investigation”.180 I agree with that assessment.
In passing I note that at the inquest Officer Mackay said he did not agree with the conclusion expressed by the Homicide Squad investigator, namely that “the failure to locate NW proved fatal”, and as he noted: That’s an opinion only. We don’t have an extensive timeline of events that happened between NW and Walkerbear on the evening and, as such, that opinion cannot be either confirmed or verified.181
Following his investigation, Officer Mackay concluded that although Officers Piahana and Burtnyk had not neglected their duty to investigate a suspected family violence incident involving NW, contrary to the Police Code of Conduct (the Code), Officers Tompkins and Lee had. Officer Mackay also concluded that Officer Glasson had neglected his duty to supervise and ensure an adequate investigation of the suspected family violence incident involving NW, contrary to the Code.182 176 Exhibit 1, Vol 1, Tab 6, IAU Report - Det. A’Sen. Sgt. D Mackay (26.02.24) and ts 30.10.24 (Mackay), pp110-115 177 Exhibit 1, Vol 1, Tabs 9 & 9.1-9.4, IAU Interviews with Officers Piahana, Burtnyk, Tompkins, Lee and Glasson (various dates) 178 Exhibit 1, Vol 1, Tab 6, IAU Report - Det. A’Sen. Sgt. D Mackay (26.02.24), p7 179 ts 30.10.24 (Mackay), p110 180 Exhibit 1, Vol 1, Tab 6, IAU Report - Det. A’Sen. Sgt. D Mackay (26.02.24), p9 181 ts 30.10.24 (Mackay), p113 182 Exhibit 1, Vol 1, Tab 6, IAU Report - Det. A’Sen. Sgt. D Mackay (26.02.24), p
Officer Piahana accepted that the update she gave with respect to their attendance at 4B Carbeen Street was delayed. However, as the IAU report identified, there was the mitigating circumstance of the officers in that vehicle being diverted to a priority 2 task that absorbed their focus.
Next, there is also the matter of Officer Glasson failing to seek a briefing from EK103 about their attendance at 4B Carbeen Street. But also, as the IAU report identified, this occurred in the context of Officer Glasson’s attention being diverted by other tasks, including managing that priority 2 job.
The next matter to identify, and this is one of the most significant, is that Officers Glasson, Tompkins and Lee failed to appraise themselves fully of (CAD Task 1) at the point in time that it was dispatched to EK101, which meant that all three officers overlooked the update that was provided by (Ms Nipper’s) ‘000’ call at 10.21 pm.
And then finally, there is the matter that Officer Glasson closed (CAD Task 1) without either NW or Walkerbear being located, which he accepts with the benefit of hindsight he should not have done. [Empasis added]183
183 ts 30.10.24 (Paljetak), p137-138
[2024] WACOR 51 Conclusions about the conduct of the Officers
In my view the available evidence (including the IAU report, and concessions made at the inquest by each of the Officers), establishes that the police response to the suspected domestic violence incident involving NW was inadequate. Further, a combination of excessive workload, technical issues, and the failure to properly investigate suspected domestic violence relating to NW, led to CAD Task 1 being closed without NW or Mr Walkerbear having been found and spoken to.
Each of these failures is deeply regrettable. In my view, the police response to the suspected domestic violence incident involving NW could, and indeed should have been better. At the inquest, each of the Officers was asked whether their approach to their duties had changed following NW’s death and their responses were: Officer Piahana: It has…been a blessing and a curse, blessing in the sense that I always err on the side of caution now, and a curse in the sense that I carry a lot of fear at even just basic jobs…I get fearful that something bad like this will happen again. So yes, it has changed the way that I police, because I think I always am a lot more cautious.184 Officer Burtnyk: [Y]es, at the end of the day I just try to overthink a little bit more than normal, and just try to be more risk adverse and just try to cover off a lot more points and ask more questions.185 Officer Lee: Since…this incident, and coincidentally, since I became a detective…it’s almost a cornerstone…when I approach a job is to allocate an investigating officer…for me, my biggest lesson is…the reason why we should take accountability from the get-go. Had I considered myself at the time as an investigating officer of a domestic violence incident, I would have made it a priority to go through (CAD Task 1) and I would have found that entry (i.e.: Ms Nipper’s call)…That is, for me…a big miss as an investigator. So yes, at the time I wasn’t a detective, but I did…protracted investigations in the inquiry team and so I…had…sufficient experience, so…there’s no justification, really.186 184 ts 29.10.24 (Piahana), p30 185 ts 29.10.24 (Burtnyk), p47 186 ts 29.10.24 (Lee), pp67-68
[2024] WACOR 51 Officer Tompkins: This investigation has deeply affected me for the last three years. It has fundamentally changed me as a police officer. I’ve taken this experience to heart, but also used it as a lesson to improve how I approach my duties. Overall, I ensure that I fully understand every situation before making decisions. There’s a lot that I’ve implemented, and, yes, I wish we had done more on the night.187 Officer Glasson: On just a personal level, I have…you know…(thought)… about a lot of it, and moving forward…It’s hard to explain, how to articulate. Just do more research. I guess I should have made more attempts to try and locate (NW and Mr Walkerbear) and, as you mentioned, the phone calls and stuff and so forth.188 Did police cause or contribute to NW’s death?
In a general sense, it may be possible to say that had police found NW on 9 October 2021, she may not have been killed by Mr Walkerbear in the manner that she was. However, in my view when properly construed, a determination under s22(1)(b) of the Act requires more than a finding of mere possibility. Instead, a finding of causation requires a more direct and palpable link between the relevant events and the relevant person’s death, and any such finding must take account of the Briginshaw principle to which I have already referred.
When Mr Walkerbear was sentenced to 11 years’ imprisonment for NW’s manslaughter, this was on the basis that he had killed NW on 9 or 10 October 2021.189 Although the manner of NW’s death could not be determined following a post mortem examination, it is clear Mr Walkerbear brutally assaulted NW before she was partially buried.
Although I have concluded that the police response to the suspected domestic violence incident involving NW was inadequate, after carefully considering the available evidence, I have been unable to find, to the relevant standard, that any failure by any member of the Police caused or contributed to NW’s death.
187 ts 29.10.24 (Tompkins), p81-82 188ts 30.10. 24 (Glasson), p104 189 Exhibit 1, Vol 1, Tab 23, [2023] WASCSR 33, Sentencing remarks per Quinlan, CJ (17.11.23)
Although NW declined to give a statement confirming Mr Walkerbear’s assault, it is true that she obtained an FVRO and that she appeared to be contemplating returning to the Northern Territory. However, she did not do so and it is therefore unclear what she would have done had she been found by police prior to her death.191,192,193 190 Exhibit 1, Vol 1, Tabs 11 and 11.1, Statements - Ms D Nipper (22.10.21 & 28.10.21) 191 Exhibit 1, Vol 2, Tab 71, Statement - FC Const. L Tompkins (27.11.21), para 42 and ts 29.10. 24 (Tompkins), p78 192 Exhibit 1, Vol 2, Tab 27, Transcript of proceedings - Magistrates Court at Kununurra (28.07.21) 193 Exhibit 1, Vol 2, Tab 29, NW’s FVRO records - Magistrates Court at Kununurra
Recommendation No. 2 Given the importance of ensuring a high quality response by police officers to incidents involving domestic and family violence, the Western Australian Police Force should consider making the face-toface training developed by the Family Violence Division (i.e.: The Family Violence Learning Event) mandatory for all front line duty police officers.
The Western Australian Police Force should also take all necessary steps to ensure that this face-to-face training is funded on an ongoing basis, whether by way of internal funding allocations, or by way of funding obtained from external agencies and/or the Treasury.
Comments relating to Recommendations
Counsel were asked to forward any comments on the proposed recommendations to the Court by 20 November 2024.194 194 Email - Mr W Stops to Ms R Paljetak (30.10.24)
Several calls to emergency services were made seeking police assistance in relation to a suspected domestic violence incident involving NW. After carefully considering the available evidence, I concluded that the police response to these calls was inadequate.
While I endorsed the conclusions reached in the IAU report in relation to the attending police officers and their supervisor, for reasons I expressed, I was unable to conclude, to the relevant standard, that any member of the Police had caused or contributed to NW’s death.
I note with approval the strategies that the Police are undertaking to improve the reliability of communications in regional areas. I also strongly support the initiatives being championed by the Police Family Violence Division in relation to improvements and enhancements to officer training, and policies and practice.
I made two recommendations aimed at enhancing the police response to domestic and family violence incidents, and I am heartened by the fact that the Police have endorsed both of these recommendations.
195 Email - Ms R Paljetak (Counsel for the Police) to Mr W Stops (07.11.24)
The increasing prevalence of domestic and family violence incidents is of significant concern to a range of Government agencies including the Police. In an online article about domestic violence published on 30 October 2024, the Premier was reported as saying that: [T]ackling the rates of family and domestic violence was an “incredibly huge challenge”. “The biggest, worst part about it is that it’s so pervasive and large that it’s cultural” he said. (The Premier also said) “You’ve got to shift the culture to stop this scourge on society, and it’s not something that we can just pass a law and implement a police response or carry out a different action, and expect it’s going to turn around. It’s going to take time, and it’s going to take the whole of society to change behaviour”.196
In concluding this finding, I wish to convey to NW’s family and friends, on behalf of the Court, my very sincere condolences for their terrible loss.
MAG Jenkin Coroner 2 December 2024 196 Caporn, D, ‘Domestic violence order breaches soaring…’, The West Australian (online article published on 30.10.24)
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