August 18, 2025 • 69 mins
Armed with a crossbow, Ryan Pringle hunted police through pitch-black bushland at the School of Happiness commune. Former Deputy State Coroner Hugh Dillon, who presided over the inquest, and Gary Jubelin, who led the investigation, walk through every moment of the terrifying manhunt.
From the chaos of that night to the Quakers Hill nursing home fire, the retired coroner shares some of the cases that impacted him most during his career, as well as calls for urgent reforms to fix the coronial system.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:01):
The public has had a long held fascination with detectives.
Detective see aside of life. The average person is never
exposed her I spent thirty four years as a cop.
For twenty five of those years, I was catching killers.
That's what I did for a living. I was a
homicide detective. I'm no longer just interviewing bad guys. Instead,
I'm taking the public into the world in which I operated.
(00:23):
The guests I talk to each week have amazing stories
from all sides of the law. The interviews are raw
and honest, just like the people I talk to. Some
of the content and language might be confronting. That's because
no one who comes into contact with crime is left unchanged.
Join me now as I take you into this world.
(00:46):
In part two of my chat with former Deputy State
Coroner Hugh Dylon, we talk about some of the cases
you oversaw in his nine years as a deputy state coroner.
We talk about murders, about suicides, missing persons, and even
critical incidents that's where someone has died as a result
of a police operation or in custody. But probably the
(01:08):
most important thing we talk about is how we can
improve the coronial system. We're lucky to have someone who's
experiences Hugh Dylan to talk about such an important role. Hew,
welcome back to our catch Killers.
Speaker 2 (01:22):
Thank you Gary.
Speaker 1 (01:23):
It's great sitting down talking to you. In saying that,
it just makes me reflect on all the things that
you see and do in the career that you've had.
In the amount of times I've been in the Coroner's court.
One of the things about the Coroner's court I did
most of my career in Glebe Currenter's Court, or even
now that at Westmead, I'm glad the courts have finally upgraded.
Speaker 2 (01:48):
Yeah it's a pretty spick and span new building. Yeah,
I'm not quite sure the system is, but maybe we'll
get all.
Speaker 1 (01:55):
We're going to talk about the system, because I'm always
in a grants something could be improved, and especially something
as important as the coeronial process, we should at the
very least talk about it. So we'll definitely cover off
on that. But I remember with the Globe Coronis Court
because quite often there's people that there's the families of
(02:15):
the victims and there's also people that the family suspected
being involved, and there was a very small meeting point
and from a police officer's point of view, trying to
keep the parties apart was near impossible in that environment.
Speaker 2 (02:28):
Yeah, I imagine. So I fortunately didn't have to deal
with that myself, but I was aware. I was constantly
aware of the potential for clashes or even for the
need for security on occasions, fortunately not very many. Yeah,
(02:49):
but yeah, that could be very tense meeting places. It
was a very confined environment.
Speaker 1 (02:55):
It made it difficult. One case I want to talk
to you about, and I want to talk in general
about critical incidence, But just as a point of reference,
was the death of Ryan Pringle as a result of
a police shooting. Now. I think that was in twenty twelve.
It was up in Tenterfield. I was a senior investigating
(03:17):
officer for that, for the Critical Incident Team. I was
working in homicide and got called out I think it
was a Sunday night, and flown up to ten to
fill the circumstances in which that occurred. You and I
have spoken about it, because you ever saw the inquest
into the matter. It was quite horrific, wasn't it.
Speaker 2 (03:37):
It's extraordinary. That was a truly nightmarriash case. Usually when
police are involved in some sort of scenario and someone dies,
they've come on a scene where someone's threatening others and
so forth. In this case, mister Pringle was actually hunting
(04:01):
the police themselves, which was well put me a mind
of the film Deliverance.
Speaker 1 (04:09):
You say Deliverance, And it was a horrendous situation. As
I said, I got called out on a Sunday night
flowing up there what happened in this particular situation that
was at a farm that was called the School of Happiness,
which was a type of a hippie gathering if you
would probably a way of describing it. There for a festival,
(04:32):
and they were camping down near a river, so there
was a lot of vans and different things and buses
down there a river, and Ryan had been involved in
a confrontation with some of the members at this festival.
Police have been called and that it's public record. I
(04:54):
mentioned their names, Karen Peasley and Carter that Knivett were
called out and they were actually married, their husband and
wife team. They've gone out to this location and there's
no communication. So we're looking at Tenterfield, the town. It
was about an hour's drive out from there, in a
very remote location with no communication. Not just a police
(05:18):
radio telephones. There was black spots all over the place.
They get out there and Ryan's decided to start stalking them.
The police I thought were very brave in that they
went and gathered up all the people at the festival
and got them all to travel out. Was like a
wagon train, getting getting everyone to pack up their gear
(05:40):
and getting their vans and follow the police car. Just
as they're about to move off, and this is in
late at night and the pitch black there, Ryan's come
out of the shadows and calling out the police and
threatening to kill them, and it ended up in a
chase round a van and taser was deployed and then
(06:01):
eventually Ryan was shot before and he had a laded
cross aimed at the police. Absolutely horrendous circumstances. I compiled
the brief of evidence and provided to you as a coroner.
What's your takeaway from a situation like that? Because no
one wins, a person's lost their life, but the people
(06:23):
have been terrified by witnessing what had occurred. What's your
takeaway from an incident like that?
Speaker 2 (06:30):
Well, I think there are a number of takeaways. The
first The first thing is, obviously your life has been lost,
and in this particular case, there were tragic elements of it.
Ryan lost his life because he threatened the police and
(06:52):
they acted in self defense. But whether he was mentally
sound or not, you'd have to you'd have to doubt
it'd been dabbling in drugs and so on and so forth,
and so that said something sad about his life. I
think his father I remember being very affected by Ryan's death,
(07:13):
but not angry so much as sad, and I felt
really sorry for him, and of course for the extended
Prinkle family. The Prinkle family has to live with Ryan's death.
But unusually, the police here were almost victims themselves, and
(07:39):
I can't imagine how terrifying that must have been, to
be honest, to have someone hunting you with a crossbow,
as you said, pitch darkness, armed only with tortures and
so forth, and the torch, of course, could show show
Ryan where you were as much as possibly illuminate him.
(08:04):
So an incredibly frightening situation. And then the police were
trying to protect a whole gaggle of people who were
simply there for a good weekend and so forth. They
were ordinary country police, you know, just decent people trying
to protect members of their community and suddenly they're being
(08:27):
hunted for their lives.
Speaker 1 (08:28):
Well, the way you describe it them referencing the movie
Deliverance had that feel about it because they were being
hunted and he was calling out, addressing camouflage gear, making
threats against them, asking all the other people to join
in and kill the police. It was something that was surreal,
(08:49):
and I remember part of my role as a critical
incident investigator that I had to interview the police involved,
and I thought that very professional, but it was traumatic
listening to them recount what had happened, and at no
point they could shine their torch, but then they'd have
(09:09):
to turn their torch off because if they're shining their
torch trying to see in the dark where he was
coming from, they potentially made themselves targets exactly, and they
did everything they could to avoid the confrontation and all
the warnings and literally running around the van with him
chasing them. It was just a horrendous situation. And then
(09:32):
add to it, and I think it gave me a
lot of respect for what country cops do, Like there
weren't there wasn't any backup for them, the communications. It
was an hour or two before other police came by.
You've got the other people in the situation. Someone's just
been shot and critical injuries and they're left there dealing
(09:54):
with that. I think Carter told me he wasn't sure
if the rest of the community were going to attack
him after the shot, and he thought that might be
so just a horrendous situation.
Speaker 2 (10:06):
Very horrendous and very courageous of them. Yeah. Well, one
of the recommendations that came out of the inquest was
that they'd be awarded some sort of gallantry metal accommendation,
which I think they received later on.
Speaker 1 (10:24):
Yeah, they did. Know. I've seen a lot of things
in policing, and that was one that was right up
there because they didn't have to stay. They could have
just driven out, but they were protecting the public in
classic what police should be doing, and putting their own
own situation at risk and doing that. There was in
(10:45):
all the darkness you do see some humor, and the
people that you would expected a gathering of the Moon
Festival or whatever on the School of Happiness Farm were
an eclectic group of people. There was one I can
say this, I don't think he'd take any offense. I
think he'd be proud of it. There was one particular
person that was a witness to this situation that he
(11:08):
didn't believe in wearing clothes. Clothes just weren't his scene.
And I don't think you realize, as the deputy state
coroner how much work we had to go do behind
the scenes to get that witness to appear in court
with some clothes on.
Speaker 2 (11:24):
I didn't know that.
Speaker 1 (11:25):
We explained that, you know, it's probably a situation where
you should wear your clothes, but I don't believe in clothes. Man,
not my scene. I think we convinced him that we're
a pair of shorts and a singlet. That's as close
as we could get him. But he was itching because
he just didn't like clothes. And I think there was
another witness. I don't think it was that one that
(11:48):
when he was being sworn in, and I'm not saying
this verbatim, but it was pretty much along the lines
of what is your what could you please tell us
your name? I don't have a name, I'm an entity,
and then produced a piece of paper from his pocket
and produced that. And you handle it very well as
a coroner.
Speaker 2 (12:10):
I knew I was dealing with some interesting characters.
Speaker 1 (12:13):
Yes, well, and the hippie bus. We had to find
a place that he could park the hippie bus that
wouldn't be stolen. There was all sorts of behind the
scenes work that you just don't understand on that and
we're laughing about as a tragic situation. But something that
when we talk about the emotion of a matter like
that is Ryan's father acknowledging the police, not blaming the police.
(12:37):
And I thought that was that was a really moving
moving part.
Speaker 2 (12:41):
Yeah, he was. He was very gracious and very stoical.
Clearly quite a well known person because he was a
well known footballer and it must have been a tremendous
blow to him to lose his son, but also some
degree of humiliation, I think, Yet he was. I thought
(13:04):
it was quite noble, really he was.
Speaker 1 (13:06):
I stayed in contact with him and had a few
communications with him, and he was very pragmatic about it.
He was suffering from the loss of his son, but
he understood the situation that it was probably inevitable what
that was going to be the end result with how
his son's actions were. But yeah, it was a strange one,
but they're the type of things and I want to
(13:29):
speak to about critical incidents because people don't fully understand
the role of the coroner in a critical incident. Critical incidence,
when we refer to that in policing, is where during
the police operation someone's lost their life, and that might
be a police shooting or a car chase. Critical incidents
are set up as a homicide detective. If someone's been
(13:51):
shot by police, there'll be a homicide inspector heading up
the investigation. Then we have to present the matter to
the coroner. There are always cantentious issues. What's your thoughts
on the way critical incidence are handled well?
Speaker 2 (14:06):
One large I thought they were handled pretty well. One
of the classic criticisms of it is that New South
Bale's police are investigating New South Bal's police. In some
other jurisdictions you have police from other you say, police
(14:27):
forces or whatever. I think ideally would have independent another
independent police force doing them. But coroners are meant to
be the people who provide the independent oversight and providing
and I think it in practice does work pretty well
(14:49):
because coroners are also assisted by people from the Crown
Solicitor's Office, and then there's in police cases as usually
a barrister from the independent bar very often a silk
who is independent. They have an ethos of independence, and
(15:12):
some of the council assistant I've worked with have been
really quite rigorous in demanding from the police investigators that
they do various things, or investigate various questions, or make
various inquiries. So I think in practice that works pretty well.
(15:35):
But that said, there are people who, no matter how
well it actually works in practice, are suspicious because it
is New South Bale's police carrying out the critical incident investigation.
I know in the parliamentary inquiries in New South Bale's coroners,
(15:58):
I think it was the Jumbunner Institute, which is an
institute at University of Technology. It's an indigenous research group
made a submission that coroners were captured by police. And
there's a concept of regulatory capture that the pop you're regulating,
(16:23):
the regulators are regulating, capture the inspectors or the regulators.
So the argument was, unless you had an independent police
force doing the investigations on behalf of coroners, that the
New South Wales Police Force would basically possibly potentially capture
(16:45):
the coroners. And so that you know the police and
the coroners would think alike, that's psychologically possible, but where
do you get the independent investigators.
Speaker 1 (16:57):
That's I've got a got thoughts on critical incidence because
a large part of my career is spent tied up
on critical incidence, and I could be in the middle
of a murder investigation, a critical incident would occur and
that got priority. My frustration was the amount of time
I was spending on critical incidents when I'm in the
(17:18):
throes of a homicide investigation. But that's just from a
resourcing point of view. I think a perception is the
most difficult thing to overcome. The families and many a
time I've introduced myself to the families as I'm the
person ever seeing the investigation into the death of your
loved one, and the initial response police investigating a police
(17:43):
because there's anger and we're making the introductions fairly early.
There was always anger and a lack of trust. And
I've got to say, in defense of the police or
my observations of the critical incidence that I've been involved in,
whether I'm leading it or working on it, there is
a degree of independence where that's why they bring the
(18:03):
homicide in and part of the process. For someone on
the critical incident, you're not allowed to know the police
or not to have a connection with the police involved
in the incident, and that would discard you from the investigation.
So I think there is a degree of independence, but
I think everyone would be better off if we did
(18:25):
have someone else to investigate it. And there's a lot
of oversight that goes into place. We have professional standards
overside in the work that homicide are doing. Is independent
officers just a thought I always and I tried to
sell this when I was in the cops. I'm sure
I'm not going to be able to sell it now,
but let me try one more time. You need the
(18:47):
skills to investigate the death of a human. Homicide detectives
have got those skills. I always thought the way a
critical incident could be run is that homicide get called
out for the first forty eight hours and make sure
the crime scene is preserved, witnesses, identified, lines of inquiry,
all the things set the investigation up. Then you could
(19:08):
bring in other people independent to come in and complete
the investigation. So homicide are basically just setting the investigation
up in a direction, and then that independent body because
you can't have in the state police coming in because
it takes too long for them to get to the scene.
So you've got to have people be able to respond.
Homicide is set up to respond twenty four to seven
(19:30):
at short short notice homicide there and then perhaps police
from interstate or a different the investigative body because you've
seen it. I know you've seen it. We've been speaking
to people that have that view. They won't be satisfied
that police are investigating investigating police.
Speaker 2 (19:49):
Yeah, that's right, and I think that's hard on the
people who the police officers who do a really thorough
investigation fair number of critical incident in quests, and only
on a couple of occasions was I a bit doubtful
(20:09):
about or did I have any doubts really about the
quality of the investigation or the initial quality. And by
and large those problems will solved because I would have
a confidence with my counsel assistant and solicitor and we'd say, okay, well,
(20:33):
detective so and so it doesn't seem to be thinking
about this or that, or maybe you know, hasn't hasn't
explored this issue or something, and then we would and
under the coroners Act. You can actually direct police to
do various things. Don't like, you know, pulling rank in
(20:54):
that way if you get cooperation. But if you need to,
you can do that. I prefer to say it as
a as a partnership. But a couple of times, in
a couple of cases anyway, council assisting said to me,
I don't you know, I think we need to get
the whip out and give me a bit of a
(21:16):
tickle up or something like that.
Speaker 1 (21:18):
I don't think it hurts that there's a safeguard if
something's missed now, whether it's through laziness and competence.
Speaker 2 (21:24):
Or just usually busy.
Speaker 1 (21:27):
Yeah, well that was that. Yeah, I started off talking
about it. My gripe was I've just been in a
homicide of a critical incident that was priority because higher
up the police realize that there's going to be criticisms,
so we're going to say, well, we've got the people
with the appropriate skills investigating when the death has occurred
(21:48):
mental health factors that come into police students, because time
and time again I saw that. Have you got any
thoughts on that? I know on the back of the
Courtney topic inquest, there was a lot of recommendations about
police training for mental health.
Speaker 2 (22:03):
Yeah, I've actually participated a couple of times with LEASA
topic Courtney's mum in talking to police about all of
those scenarios. Incredibly difficult. Ideally, what you'd always have if
(22:24):
someone is psychotic in some way, you'd have a mental
health team who possibly would be escorted by police, but
the mental health team would be the first responders rather
than police, I think. I mean, it's very very difficult,
isn't it, when police, who are very often very young,
(22:49):
are the first responders to people acting dangerously to themselves
or others. And I've seen this happen. I've seen police
training where you know, people have shown how to back
off and various techniques for trying to talk people down
or keep them corraled in a safe space. But sometimes
(23:14):
you run out of space, and then it's and then
it can be a question of basically self defense. And
I know, well, certainly I've done cases where police have
shot people just too I think, and they were certainly
in self defense, but they're shattering for everybody afterwards.
Speaker 1 (23:42):
Well, I haven't seen a police offer so that it's
been involved in a shooting incident, hasn't been affected. It's
as much bravado that can come up after shooting incident
and police know I'm fine. It does have an impact.
There is consequences.
Speaker 2 (24:02):
There are consequences, and I think you know, everybody knows,
everybody who's involved in these things knows that was another
human being, yeah, just like me. And they've got a family,
and they see the family at the inquest. Personally, I'd
like to see lawyers who represent police officers and the
(24:23):
Police Association try to persuade cops who involve police that
turning and facing the family and apologizing yeah, might be
a good thing for their own mental health.
Speaker 1 (24:40):
It's interesting you say that I'm not going to talk specifics. Well,
I've seen cases like that. It's almost if you talk.
There is that little bit of adversarial in the inquest
and a critical incident, and I see police react like
they want to just break down and cry with the family,
and it would be benef official for everyone involved, But
(25:02):
there's a sort of a stoic front that no, we're fine,
we're just doing our job. And I've heard police in
the witness box saying, look, I ran an operation where
someone was shot and killed, and I acknowledged that, and
I was being cross examined about well, it was a success,
(25:22):
wasn't it, And I've said, no, it couldn't be further
from the success. I'm devastated by it. That was my
true belief. But I've seen police that I think anyone
would be of that view stand there and try to
put on the brave front. No, they got what they deserved.
My life felt threatened, and it just aggravates a family
traumatized as a family, and I'm sure it traumatizes the police.
(25:44):
So yeah, and I think sorry, I think it is
part of the legal advice. Don't don't concede anything here,
and you did the right thing, but you can show
emotion and still do the right thing.
Speaker 2 (25:59):
Yeah, and even if you did have to act in
self defense, and in most of those cases that's exactly
what happens, you can say, yeah, but I really regret
doing this, and I can see how affected you are.
(26:21):
Kirsten Edwards said, I'm sure you've come across an in quest.
Very very good barrister who I think has sometimes represented
police in in quests told me about a case in
which she had seen a young cop break down in
tears and say something to the effect that to the family.
(26:44):
I think about your son every day of my life,
and if I could go back and prevent this happening,
That's what I'd love to do. And the family, the
family I think probably wanted to see his pain, not
just feel it themselves. And having and Kirsten Tommy that
(27:05):
having seen him breakdown like that, they were much more
willing to accept what had happened, to forgive him and
to see him as a fellow human being. And if
we can see one another as fellow human beings instead
of them and us always you know, you're the other,
(27:28):
I'm the strong one, I was just doing my duty
or whatever. I think we go a long way to
making these increase a very traumatic for everybody, but we
would do a great deal to reduce the trauma that
they cause to people, families, police, correctional officers, whoever. If
(27:53):
we could show that, if witnesses could show that they
they are her to I think it would be really
good if we could get inquests on more quickly, because
I think the longer that the time lass. But yeah,
it does. And people not only come up with their
(28:14):
own theories of how this death came about, which can
be can be right, but very often wrong. That can
be very difficult for people's mental health as well. But
I think I think there is a I think in
grieving psychologically, there's a sort of a sweet spot. You
(28:38):
need some time to get over the initial impact and
then you can think about what actually happened, and if
you if you can hear from the people who were
involved what happened at that moment. In that sweet spot,
then I think you are more likely as a as
(28:59):
a fan only of someone who's died, or as someone
who was involved in the incident, the fatal incident, maybe
even the person who caused the death, I think you're
more likely to come up with some chance of healing
in maybe not immediately, but over time.
Speaker 1 (29:20):
Well, what you're saying there are words of wisdom, and
I suppose that comes from seeing the emotions as rule
as it is for as long as you did in
the environment. It's confronting. But what you talk about, I
think we could encapsulate that in the word of just
bring some humanity to it.
Speaker 2 (29:39):
And I mean, I'd like to think that the Police
Association and the Public Service Association and those sort of
people with the unions would say the benefit of this too,
because sometimes I think thinking legalistically is not necessarily the
(30:00):
best way to think about these things.
Speaker 1 (30:01):
Yeah, and that's exactly how it's approached from the police
point of view, and there's so many more layers to
it than just from a legalistic point of view. Another
thing that sounds counterintuitive when I say this, but mental health.
And we talked about how that could be navigated if
there was someone there with the expertise when police respond
to those type of jobs. But I'm concerned. I'm saying
(30:24):
this now as a former police officer, but seeing what's
gone on the lack of training, tactical training. Now we're
trying to reduce police shootings. Tactical training is not just
pulling out a gun and shooting someone. It's been comfortable
in the environment, knowing how to handle yourself, knowing how
to de escalate confronting situations. Police are entitled to use
(30:47):
their firearm if they fear for their life. If we
could train people, train police with more training. Now I'm
not sure I've been out for years now, but the
amount of training days, tactical training days we do, I
think it's one a year, like you have a shoot
once a year. Now, I was involved in tactical policing
(31:07):
where we had to shoot the minimum once a month,
and it was just so it became repetitive. You felt
comfortable with your weapon from when I joined the police.
And now what the young police are carrying these days,
with the tasers, the OC spray, of the expandable battern,
and they've got so many other things. It's complicated in
(31:28):
a time of stress, how they're going to react. I
just think we need to and I know there's a
cost associated with training police, but we need to dedicate
more time to training.
Speaker 2 (31:40):
Yeah, well that doesn't surprise me you say that, because
almost always in these inquests, the question of tactics comes up,
doesn't it. And you often find that when you boil
it down, some of these deaths are ventable and they
(32:01):
could have been prevented had better tactics being employed. So
you know, there's training days that I've been up to
see how participate in with lesser topic. Police have shown
videos of how to retreat from a dangerous situation, et cetera,
et cetera, But how well does that actually work in practice?
(32:25):
And I quite often think about a particular case, this
is ut in Western News, South Bales I won't use
the man's name because he was an Aboriginal man, but
he was shot and killed by police or a police officer.
The police officer was acting in self defense because the
(32:46):
Aboriginal man had attacked him with a club block. But
there'd been an earlier incident. The police were looking for
this man and they suspected he was in a house.
And I sometimes wondered how good a job I did
(33:06):
as a coroner, because although I had a very good
counsel assisting, one of the questions that I later thought
about was the tactical issue. The police entered the house
thinking he may be inside. They entered the room and
this man was in there, and the officer pulled out
(33:26):
his taser and tasered the man that had, as far
as you could see, no effect on you except to
mak him even angry. He had this club like instead
of whacking the officer around the head and shoulders, and
the officer managed to get his gun out and went
bang bang. Now had the police what I now think
(33:48):
is and had we asked for more expertise on tactics,
you know, could the police have tactically secured that house
better discovered whether or not the man was in the
house before they actually entered the room he was in.
(34:08):
I don't know the answer to that, but I kicked
myself quite regularly when I think about this, for not
having at the time raised the question. In the end,
we walked away. I'm sorry, you know, terribly sorry. The
man's father was there. There was a group of Aboriginal
people who were very angry, you know, and they saw
(34:32):
it as just another day in the colony, I guess
something like that. They could not accept that this death
had come about through any thought of anyone except the police.
And I thought, if I now think, if I'd done
a better in quest, it may have made absolutely no
(34:55):
difference to the community, the Aboriginal community. We would have
got a better answer, I think, and we might have
been able to we might have come up with the
recommendation that would have made this sort of situation safer
in future.
Speaker 1 (35:13):
Well, there was a police shooting and going back a
very long time ago where tactically it became more contained
than negotiat rather than going in with the tactical teams
the active shooter scenarios. Now that's had to be adapted
for current times and the threats. But yeah, I don't
(35:34):
think you can get enough training in that type of
the type of situation, and you are reacting in what
could be the most stressful situation that you've you've encountered,
and you need to be able to think clearly, and
that only comes through with training. I think it's something may.
Speaker 2 (35:51):
Only happen once in your life. Yes, please, I've said,
but if you can't react instinctively, instinctively in the most
appropriate way, can I tell This reminds me of a
case that amused me. Actually it didn't, it didn't have
a terrible ending. And that happened while I was a magistrate.
(36:14):
To police go to go to the door of the house,
the knock on the door, they said, please, please, you
open the door. Anyway, they opened the door and a
guy comes rushing down the hallway waving a samurai sword
and the police officer, I was a magistrate, not a
coroner at that stage. That the guy was charged with
(36:37):
dangerous weapon or something like that. Anyway, the police. What
amused me was this police have a funny way of
writing statements. So and one of the ways they write statements,
so that must be taught this in the academy. Is
you don't say. I said, blah blah, you say. I said,
words to the effect of and this police office. I
(37:00):
said something like I saw a man running down the
hallway waving a samurai saw it. I said, where's the
effect of fuck retreated? I said, words the effect of
police Please, we're under arrest. He said, fuck off.
Speaker 1 (37:22):
I've seen statements statements like that. But yeah, there's training
and something stick. But yeah, I see the funny side
of that. I want no names, no pack drills. But
I went back as a crime manager and there was
a young officer and just needed educating, and she was
trying to do things properly. She's given a statement, and
(37:45):
I had to go through the briefs of evidence and
look at the brief of evidence, and someone brought that
to my attention that hey, boss, can you have a
look at this evidence of all this brief I've got
some concerns, and basically she's gone. I think it was
a domestic situation a I don't say domestics minor, but
it was a rather minor thing. And she's communicating in
(38:06):
a level that people would understand. She's going, well, this
is the police officer. So I said, what the fuck
is going on here, and she said, nothing, you bitch.
Don't you call me a bitch, You're the bitch, and
like that, like that, And so I got her in
to my office and I said, look this statement. I said,
I'm a little bit worried about the wording here. And
(38:28):
she said, we were told in that we've got to
say exactly what was said. And one hundred percent I agree,
it's got to be a true account of the conversation.
And so I decided to approach it a different way.
Maybe as a police officer, we shouldn't swear so much,
like you that's what said on this occasion, But maybe
next time you're speak to a member of the public,
don't throw in so many swear words. But yeah, it's
(38:50):
all a learning process, isn't It is a learning process,
And I feel, you know, I look back at the
mistakes I made in the cops when I just got
in and yeah, I don't know how I got through
it half the time.
Speaker 2 (39:02):
Well, fortunately, coroner's mistakes don't end up with anybody getting
hurt or yeah.
Speaker 1 (39:09):
Yeah, well that's the thing. So we've covered off on
like critical incidence, and that was a a lot of
my time in coroner's courts were put through overseeing critical
incidence other cases that you've been involved in the death
of fourteen people at Quakers Hill nursing home fire. That
(39:29):
was a horrendous situation. Do you want to tell us
what your involvement overseeing that inquest? Because it was a
person I think he's Roger Dean was convicted of eleven
counts of murder.
Speaker 2 (39:42):
That's right.
Speaker 1 (39:43):
So this situation has happened, the fires were lit, the
people at the nursing home were killed. Homicide have investigated,
he's been charged, he's been convicted. What role did you
have as a coroner in that situation?
Speaker 2 (39:58):
Well, Conner has always had have a role to look
at homicide cases and these were obviously this is a
mass murder. But the reason we could have decided not
to do an inquest, this came after the murder proceedings
were over. The reason we decided to do it was
(40:21):
for a couple of reasons. One was, was there anything
that we could look at about the management of the
nursing home in relation to use of drugs or security
of drugs because Roger Dean was doctor shopping. He has
drug affected and the reason he started the fire was
(40:43):
to prevent the management of the nursing home finding out
about his stealing of drugs schedulate drugs. So he wanted
to cover up his tracks, and he was reckless. He
didn't particularly want to kill people, but he wanted to
cover up his own wrongdoing, so he set these two
(41:07):
fires and then he ran away turned up later while
the fire was being fought. Were also interested in the
response of the fire brigade of how the people were
evacuated from the nursing home, whether there were any lessons
(41:29):
to be learned about the particular fire, how it's been
responded to, the building codes, the actual fire hydrants, and
those sort of things, because there had been some difficulties
with various aspects of connecting the fire appliances to the
(41:51):
water supply and so on and so forth. So I've
forgotten how many recommendations we came up out of that.
It was a significant number. And one of the main
things that in the end we didn't have to recommend
because it came out of the case was a change
(42:12):
of the building code to require that sprinklers be installed
in all nursing homes, because sprinklers can reduce the ambient
temperature in a very hot fire enough to save lives.
These sort of fires can get up to incredible temperatures,
(42:33):
you know, six hundred degrees one thousand degrees centigrade because
they're burning lots and lots of petrochemical materials. Sprinklers can
bring it down to a couple of one hundred degrees,
at which point people can be rescued, you know.
Speaker 1 (42:50):
Okay, so that's what It's not just saving the building.
Speaker 2 (42:55):
It's saving the people is the main thing. The building
could be, but the people could be saying, yeah, yeah, do.
Speaker 1 (43:02):
Those recommendations that get followed up where they follow up.
Speaker 2 (43:06):
And they were most of them were. The fire was
far and rescue are really good at following up recommendations
and in fact, they make a really good contribution to
framing recommendations for coroners.
Speaker 1 (43:24):
Well, it's important, like the magnitude of yeah, an offense
where it's taken for their lives. It was horrendous that situation.
Some of the strange deaths you've seen, and we're not
making light of light of death. Every death, you know,
carries a weight and the impact. But what are some
(43:44):
of the things that you just wouldn't anticipate that's left
and the lasting impression on you.
Speaker 2 (43:48):
Well, one was, and this was very early on in
my time as a coroner. An elderly man was walking
his dog outside Royal and So for hospital, and somehow
he got tangled up with the dog, I think, in
the lead, and he tripped over and he broke his
(44:10):
fema and he ended up in hospital. Unfortunately, he died
of pneumonia, and because it had an accident, his death
was reportable to their coroners. Well, I became hyper vigilant
after that when I was working my dog and walking
my dog, and if anyone came near me with the dog,
(44:32):
I was very, very cautious of it. I became less
hypervigilant and more fatalistic. I guess after about a year
or so.
Speaker 1 (44:44):
But you and people stopped reporting this strange man telling
the careful when they're walking their dogs.
Speaker 2 (44:51):
Oh yeah, so I think I became less strange over time.
Speaker 1 (44:55):
I can imagine like things like that that you just
never anticipated and okay, it sort of sticks with you
for whatever reason.
Speaker 2 (45:02):
Yeah, there are others, but I think I prefer not
to describe them.
Speaker 1 (45:05):
Okay, fair enough. You explain in part one why you
left left as a coroner, and it wasn't by choice,
It was just your time to leave as a coroner. Yeah,
since you've left the coroner's court, clearly you haven't. It's
like me, I've left homicide and I'm hosting a podcast
called thy Catch Killers. You have left the coroner's court
(45:26):
and you're doing a PhD as cornial matters.
Speaker 2 (45:30):
That's right. So, even when I was working at the
coroner's Court, I really felt that the system could be
designed and structured and resourced a lot better than it was.
We used to be quite proud of ourselves, you know,
proud of the individual work that we did and so
(45:53):
on and so forth, but most of us didn't have
the opportunity to think much about how the system worked
as a system. And as I was saying right at
the beginning of the podcast, Gary, it's a multidisciplinary system.
It's not just coroners. It's not just coroners telling police
(46:14):
to do that or forensic pathologists to do this. It's
a group of people all trying to investigate deaths in
the hope of either finding lessons or at least giving
people answers. And I don't think we do it especially
well in New South Wales. The system we have was
(46:37):
it's really more or less the same, except on a
larger scale than it was in the early nineteen hundreds
when the magistrates took it over. It's still run by
the magistrates. We have better systems in Australia. There are
better systems overseas.
Speaker 1 (46:53):
I've heard you say that you rate Victoria as one
of the best. Yeah, what is it about Victoria that
sets on the side.
Speaker 2 (47:02):
Well, Victoria, Well, a few things. First of all, it
was built around a concept or two concepts really, the
two concepts being one care for families. So everything that
coroners do and the coronial system does in Victoria has
(47:22):
to take into account the effect on families and their distress. Secondly,
it was all about the second thing is the second
pillar is prevention of future deaths. And in two thousand
and eight the Victorian system was reformed from top to bottom. Well,
(47:43):
for many years that had the idea of trying to
make it more effective at preventing future deaths and injuries,
but the system itself was pretty ordinary, and in fact
they had a parliamentary inquiry in two thousand and six
which flowed from complaints being made by families about how
(48:04):
slow it was, how inefficient it was, et cetera, et cetera.
We have exactly the same sort of system as the
Victorians had pre two thousand and eight. It's not efficient.
The people who work in it are really good people,
but they're not resourced well. The system isn't structured or
(48:25):
designed to be effective or as effective as it could
or should be. It's not very good at preventing future deaths.
We only hold one hundred inquests a year, and the
only way coroners in Byales have any illegal right to
make recommendations to prevent future deaths is if you hold
(48:47):
an inquest. Well, if you don't hold an inquest, there
are no lessons disseminated to the community. There's a lot
of data collected and that's sent to a national database
in Victoria called the National Coronial Information System, but that's
mainly used by university researchers, not so much by coroners,
(49:12):
whereas it was set up to help make coroners work
really effectively. The Victorians have an in house research group.
Ontario has an in house research group. I think Nova Scotia.
Speaker 1 (49:26):
No, okay, this is from all your overseas study.
Speaker 2 (49:31):
But in New Zealand's looking at it so News up
Wales has had two parliamentary inquiries in the last three
years or four years which have recommended radical reform. And
basically the reforms being recommended are we set up a
specialist court, well resourced with in house researchers, whose job
(49:58):
would be to try to come up well first of all,
identify patterns of patterns and trends of fatalities, which could
then be fed to public health and safety authorities to
try to save lives. And I explained before not only
is there an enormous, an incalculable human cost to sudden
(50:24):
and unnatural and unexplained deaths, but there is also an
economic cost. If we could if we could make the
coronial system in news up Bales even slightly more effective,
we could save some lives and the money saved the
economic savings would pay for a new system. The News
(50:47):
Out Bail system costs around about eleven million or twelve
million dollars a year. The Victorian system costs around about
twenty seven million dollars a year. That's its compared with
what we spend on health, police, public safety. Generally, you
can have a much much better system for not very
(51:09):
much more money.
Speaker 1 (51:11):
It does seem like peanuts on the scale. It is
peanuts because a constant complaint I've had dealing with victims
families is the length of time before the matter becomes
and they're hanging there almost in a state of suspense,
waiting for this matter. And exactly if I'm saying in contact,
(51:32):
all the inquests that set down for next year, it
was going to be this year, but it's been put
off for this reason or that reason that needs resourcing,
like we need to be able to get the turnover
done quicker, would you?
Speaker 2 (51:44):
I absolutely agree. I did some research recently for an
article I wrote. I looked at all the published coronial
findings for twenty three and twenty twenty four. My PhD
about forty percent of inquests took more than three years.
(52:06):
It's now it's over fifty five percent.
Speaker 1 (52:10):
Now how that break break those figures down? Fifty five?
Speaker 2 (52:13):
Fifty five percent of inquests take more than.
Speaker 1 (52:17):
Three years to get finalized.
Speaker 2 (52:19):
To get finalized, and more than forty percent take more
than five years. Imagine having to wait that long. I
have a barrister's practicing certificate now and I'm representing a
man whose mother died in Orange hospital in twenty twenty
one and we still haven't got a date for an inquest.
(52:43):
Were nowhere near.
Speaker 1 (52:44):
And he is that because of the availability of a
coroner and availability of the court.
Speaker 2 (52:48):
Well, it's for all sorts of reasons, the investigations taking
a long time, or all sorts of reasons, but there
is a tremendous need not just for more resources, but
for a better way of coordinating these various arms of
the system. Michael Barnes, a former state coroner, at the
(53:11):
parliamentary inquiry in twenty twenty one, gave evidence and he
said words the effect of this system is so uncoordinated
that it really is a bit of a joke to
call it a system at all.
Speaker 1 (53:30):
Pretty DAMMI. And this is Michael Barnes who came down
from Queensland.
Speaker 2 (53:34):
Michael Barnes who came down from Queensland, who's now the
new South Wales Crimes Crossia. Michael. Michael really knows all
about coroners and coronial systems. He has seen most of
them around Australia. He's provided advice to many of Australian
(53:55):
and I think New Zealand coronial systems and other places.
So Michael is one of the Australia's leading experts. He
knows when he says the system not working, well.
Speaker 1 (54:06):
Well we've got to get we have got to get
it better. Haven't we like it? So I know the
trauma that causes families with delays.
Speaker 2 (54:15):
Look, I believe the Attorney General has his heart in
the right place. And the problem, of course, as it
always is, is resources and that means government money, and
that means priority. There is always enough money. The question
is where does this idea, this concept of a really
(54:38):
good colonial system sit in the order of priorities. And
it doesn't sit, in my opinion high enough. It's time
it was improved and radically overhauled.
Speaker 1 (54:51):
There's six things and this is in the article that
you're the author of. So I suspect you'll agree with
the things. Six things that need to be done to
build a modern coronnial system for New South Wales. If
I could just reimprovement, then we can discuss if you
want to one define the philosophy and purpose of the
(55:11):
coeronnial system in terms of respect and care for families
and prevention of death. I think we've already spoken about
that that was what the whole philosophy. What's it there for.
Speaker 2 (55:22):
To show recognition and respect?
Speaker 1 (55:24):
I believe, okay. Point number two rewrite the Coroners Act.
Speaker 2 (55:30):
Yeah, the Coroner's Act is out of date. It's just
a Victoria. New Zealand. Other places have much better acts.
It's so obvious a thing to.
Speaker 1 (55:39):
Do, okay, So, and that's just making it more contemporary.
The things that need to be changed work better. O
Number three. Create a specialist Coroner's Court to conduct all
coeronnial inquiries and coordinate the multidisciplinary system.
Speaker 2 (55:55):
Yeah. Well, at the moment, cases that occur in the
country are reported to LIDCOLN with the specialist coroners work
Someone has a look at the case and then it's sent.
In most cases, it's sent back to the country magistrates.
The country magistrates are not specialist coroners. They don't have
(56:16):
the resources, they don't have the training, and they don't
have the experience, and yet they're asked, on top of
their very busy criminal and civil loads, to look after
forty five percent of the state's coronial workload. It's ridiculous.
Victoria got rid of it years ago. New Zealand got
(56:38):
rid of it even earlier. Every single Australian state and
territory now confines coronial matters the coronial jurisdiction to people
who are specialists in that jurisdiction.
Speaker 1 (56:53):
Well, I got to say, you've seen here listening to
your talk and seeing how you went about your business,
and the coroners that I've appeared before, the experienced coroners,
You've got so much I call the wisdom but understanding
of what's needed in the coroner's court from the experience
that you've got. So it makes a lot of sense.
(57:14):
Point number four. Focus the system on prevention of death
by developing in house research capacity and connecting with other
public health research institutions.
Speaker 2 (57:23):
Yeah, this is what I'm talking about with Victoria. Victoria
transformed coronial practice really and everyone around the world involved
in the niche world of coroners knows this. Victoria led
the way. It's got some of the leading thinkers about
coronial practice. In Freckleton is probably the leading thinker in
(57:47):
the world is a Victorian barrister. David Rampton is a
Victorian forensic pathologist, and they are two of the leading
thinkers in in the world on this and both of
them have the concept of coigners as public health and
(58:08):
safety officials, and that means trying to prevent future debts,
looking at what the data are telling you. Instead of
taking samples of one one case or cases one at
a time and think, oh, yeah, I've got the answer
for that, why don't we look at cases and group
them together and look at what patterns and trends are
(58:29):
telling us, and then say, what lessons do we learn
from this? How do we stop this pattern or trend recurring?
And that's why I'm saying that the excuse of governments
always is we can't afford it. But if you invested
in research like that, or linked up as partners with
(58:53):
University of researchers to do this kind of research, the
savings would be so honestly incalculable.
Speaker 1 (59:02):
You're countering any arguments about what we need the funding.
You're saying, well, look at the model we're talking about.
It would be fiscally responsible.
Speaker 2 (59:11):
Do they And I've been talking to the news Outdal's
Health about this and they can see that the issue,
and I believe the Department of Community, Communities and Justice
does too. It may be that in the next couple
of years someone will say, oh, yes, it won't cost
very much and this is the bang for the buck
(59:35):
we'll get out of it. It would be a big
bang for not very many bucks.
Speaker 1 (59:39):
Okay. Point number five. Expand the resources and streamline the
processes of the system to reduce delay. I think we've
already we've touched and discussed that, and I see the
trauma that causes family, so I think that's something that
needs to be done the delays.
Speaker 2 (59:59):
Could I just so about that? But here's an obvious thing. Victoria,
almost the same number of deaths reported every year, has
fourteen specialist coroners. New South Wales at the moment has seven.
But I'm told that two of those coroners are going
back to the local court to work as general magistrates
(01:00:21):
in September. I hope that doesn't happen. I hope. But
even so we've only got seven.
Speaker 1 (01:00:27):
The disparity disparity.
Speaker 2 (01:00:30):
Queensland has ten and they have two thirds of the
workload of New South Wales New Zealand, but half the
workload of New South Wales has twenty six. So New
South Wales's government is doing coronial work on the cheap.
It's not saving the lives the number of lives it
(01:00:51):
could do if it invested in the system. It's putting
off the evil day.
Speaker 1 (01:00:57):
It's it's the important thing too, isn't it about saving lives?
Speaker 2 (01:01:01):
Ye professional lives, and it's all about carrying the families.
You know, if even if we held more in quests
and had more coroners, but you didn't hold them for
five years or three years, you might ask, what's the
point of holding it an inquest in four years time
if the impact by then will have dissipated. You need
(01:01:25):
to hold in quests within the first couple of years
after someone started. If you're going to learn the lesson
and have real impact, I think.
Speaker 1 (01:01:35):
I think you're one hundred percent right point number six.
Minimize unnecessary extra trauma for family members by making inquest
processes more restorative and less adversarial.
Speaker 2 (01:01:47):
Yeah, look, I don't think all in quests can be
non adversarial. But I in Ontario back in the nineties,
they had this idea of around table kind of a conference.
I don't know if you're familiar with the restorative justice anyway.
Restorative justice means that people who have done something, who
(01:02:08):
have caused a harm, meet the people who have been harmed,
and I think we could have a very different kind
of coernial system if that became the one of the tools,
one of the methodologies where we brought people from hospitals
and families together, or from prisons and families together, or
(01:02:34):
police and families together, or whatever it may be. Accidents
people have caused accidents and families together, because as we've
explored in this conversation, very often it's not due to malice.
Most often it's not jueitimalice. You know, homicides are very
(01:02:55):
small proportion of all these deaths. It's mostly accidental or
something of that nature, or a mistake. If people are
willing to meet and open their hearts to one another,
that I think could be or could have, but not always,
(01:03:15):
but it could have in many cases a very restorative
healing effect. It's not closure, but it could enable people
to go on with their lives in a happier, less
troubled way.
Speaker 1 (01:03:33):
Well, I'm a big advocate for restorative justice. From what
I've learned and seeing with people that come in here
and lessons that can be learned from it, I think
it's something that could be introduced into the cranial sphere.
Speaker 2 (01:03:47):
Yeah, well, if I stay current, that'll be one of
the first things I do. Really, I really would.
Speaker 1 (01:03:54):
And there's one more point. I think we're talking off
a camera that if there's how many cases are reported
to the coroner and New South Wales on average a
year six just.
Speaker 2 (01:04:05):
A bit under eight thousand now and when I read that,
it was about six.
Speaker 1 (01:04:09):
And six and a half from to three years ago,
so about eight thousand now. And we're saying we're talking
about the figures that equates to eighty thousand because of
there'd be ten people that's been impacted on by someone's death,
so and it might be twenty, it might be twenty,
so hundred and sixty thousand people. Look, it's something that
(01:04:30):
what we've talked about, the whole coronial process, it's very
close to my heart because I've seen the pain. I've
seen what's gone on and the work that happens. Ask
you a question coming to the end of the podcast.
Do you fear death in what you've seen like examining
I think as a homicide detective, I have a certain
(01:04:53):
view on death from what you've seen. What's your take
on death because you've seen it in more ways than
most people in their life.
Speaker 2 (01:05:00):
Yeah, well, there are some ways I don't want to die,
but I'm not afraid of death as such. And one
of the reasons is early on in my time as
a coroner, it took me a while to go down
to the morgue and actually see how the forensic pathologists
(01:05:21):
and their teams examined the bodies of those who have died,
and it took away the fear of death itself from me.
People are very much at peace. They're not, you know,
whatever happened to them. They're no longer in pain. And
(01:05:41):
the other thing about working or getting to know the
people in the morgue was I got to know the
social workers who deal with the families, and I honestly
think they're saints. They were such good people and such
wise and behind people that I thought, you know, I
(01:06:04):
don't know if there's a life after death or not,
but at least in this place, those who are dead
are at peace, and those who are trying to help
their families are really good people. So it's not such
a bad way to go to end up in the morgue.
But yeah, I'm not afraid of my own death. I
(01:06:29):
really feel though, that we need to save lives. You know,
people we talked about what a good death is. I
would hope our society could ensure as many people as
possible have a good death, meaning a death, a peaceful death,
a death their families can accept reasonably peacefully. And I'd
(01:06:53):
say that about our common humanity. On Sunday there was
a march about Palestine. To me, many people down there,
Jews and Palestinians, Israelis and Palestinians. I think about those
people all the time.
Speaker 1 (01:07:10):
Yeah, it's hard not to think about when you see
the stuff like we're seeing going on overseas. It's horrible.
I heard I was at a university graduation and someone
doing the talk there. It was palliative care doctor, and
he just spoke and he'd had a lot of experience
(01:07:30):
in palliative care. And a question was asked of him,
what's the most frequent question that people ask you? What's
a good death? And he said, to live a good life?
And I thought that was a nice way of looking
at it, like it's how do you define a good death? Well,
maybe live a good life.
Speaker 2 (01:07:46):
Yeah, it's funny, isn't it. Three years ago I had
a sort of near death experience and while I was
waiting for the ambulance, thinking maybe this is it. That's
exactly what I didn't feel. I've lived a good life.
I felt i'd lived a lucky life, and I had
(01:08:07):
been very lucky. You two beautiful kids, lovely partner. I've
been lucky enough to do some work that's been really interesting,
meet really good people, work with them, and so I thought,
you know, if this is the end, I've been lucky.
Speaker 1 (01:08:25):
Were you thinking about whether you should have put in
recommendation that ambulances should respond.
Speaker 2 (01:08:33):
I was watching that. I was watching the clock.
Speaker 1 (01:08:37):
Damn it, I should have made that recommendation strong.
Speaker 2 (01:08:39):
I was actually thinking of that.
Speaker 1 (01:08:41):
Ye.
Speaker 2 (01:08:42):
Hello, how's this going well?
Speaker 1 (01:08:46):
I'm glad we haven't lost yet. Hugh, And thank you
so much for coming on the on the podcast, I've
really enjoyed having a chat with you. But I just
want to thank you for the work that you've done.
And at the start of the introduction, I talk about
it's there is that you're interested in? The passionate about
is something that I share and I think, whether it's
a homicide detective or acurr. And then we see the
(01:09:07):
pain that families go through where they lose loved ones
and they have someone like you with genuine empathy, care
and the smarts to get the strong message across. Congratulations
and thank you for your efforts.
Speaker 2 (01:09:19):
Oh, thank you, Garriot. It's been really interesting and a
real pleasure for me to have a chat with you.
It's been a long time. It has been very good
to see you again.
Speaker 1 (01:09:30):
Yep, good stuff. All the best for the future, and
keep pushing, pushing the reform.
Speaker 2 (01:09:35):
Certainly, I'm going home to send a letter to somebody today.
Speaker 1 (01:09:39):
No, it's good and important work that you're doing and
a lot of people would thank you for it.
Speaker 2 (01:09:44):
Thank you very much.
The public has had a long held fascination with detectives.
Detective see aside of life. The average person is never
exposed her I spent thirty four years as a cop.
For twenty five of those years, I was catching killers.
That's what I did for a living. I was a
homicide detective. I'm no longer just interviewing bad guys. Instead,
I'm taking the public into the world in which I operated.
(00:23):
The guests I talk to each week have amazing stories
from all sides of the law. The interviews are raw
and honest, just like the people I talk to. Some
of the content and language might be confronting. That's because
no one who comes into contact with crime is left unchanged.
Join me now as I take you into this world.
(00:46):
In part two of my chat with former Deputy State
Coroner Hugh Dylon, we talk about some of the cases
you oversaw in his nine years as a deputy state coroner.
We talk about murders, about suicides, missing persons, and even
critical incidents that's where someone has died as a result
of a police operation or in custody. But probably the
(01:08):
most important thing we talk about is how we can
improve the coronial system. We're lucky to have someone who's
experiences Hugh Dylan to talk about such an important role. Hew,
welcome back to our catch Killers.
Speaker 2 (01:22):
Thank you Gary.
Speaker 1 (01:23):
It's great sitting down talking to you. In saying that,
it just makes me reflect on all the things that
you see and do in the career that you've had.
In the amount of times I've been in the Coroner's court.
One of the things about the Coroner's court I did
most of my career in Glebe Currenter's Court, or even
now that at Westmead, I'm glad the courts have finally upgraded.
Speaker 2 (01:48):
Yeah it's a pretty spick and span new building. Yeah,
I'm not quite sure the system is, but maybe we'll
get all.
Speaker 1 (01:55):
We're going to talk about the system, because I'm always
in a grants something could be improved, and especially something
as important as the coeronial process, we should at the
very least talk about it. So we'll definitely cover off
on that. But I remember with the Globe Coronis Court
because quite often there's people that there's the families of
(02:15):
the victims and there's also people that the family suspected
being involved, and there was a very small meeting point
and from a police officer's point of view, trying to
keep the parties apart was near impossible in that environment.
Speaker 2 (02:28):
Yeah, I imagine. So I fortunately didn't have to deal
with that myself, but I was aware. I was constantly
aware of the potential for clashes or even for the
need for security on occasions, fortunately not very many. Yeah,
(02:49):
but yeah, that could be very tense meeting places. It
was a very confined environment.
Speaker 1 (02:55):
It made it difficult. One case I want to talk
to you about, and I want to talk in general
about critical incidence, But just as a point of reference,
was the death of Ryan Pringle as a result of
a police shooting. Now. I think that was in twenty twelve.
It was up in Tenterfield. I was a senior investigating
(03:17):
officer for that, for the Critical Incident Team. I was
working in homicide and got called out I think it
was a Sunday night, and flown up to ten to
fill the circumstances in which that occurred. You and I
have spoken about it, because you ever saw the inquest
into the matter. It was quite horrific, wasn't it.
Speaker 2 (03:37):
It's extraordinary. That was a truly nightmarriash case. Usually when
police are involved in some sort of scenario and someone dies,
they've come on a scene where someone's threatening others and
so forth. In this case, mister Pringle was actually hunting
(04:01):
the police themselves, which was well put me a mind
of the film Deliverance.
Speaker 1 (04:09):
You say Deliverance, And it was a horrendous situation. As
I said, I got called out on a Sunday night
flowing up there what happened in this particular situation that
was at a farm that was called the School of Happiness,
which was a type of a hippie gathering if you
would probably a way of describing it. There for a festival,
(04:32):
and they were camping down near a river, so there
was a lot of vans and different things and buses
down there a river, and Ryan had been involved in
a confrontation with some of the members at this festival.
Police have been called and that it's public record. I
(04:54):
mentioned their names, Karen Peasley and Carter that Knivett were
called out and they were actually married, their husband and
wife team. They've gone out to this location and there's
no communication. So we're looking at Tenterfield, the town. It
was about an hour's drive out from there, in a
very remote location with no communication. Not just a police
(05:18):
radio telephones. There was black spots all over the place.
They get out there and Ryan's decided to start stalking them.
The police I thought were very brave in that they
went and gathered up all the people at the festival
and got them all to travel out. Was like a
wagon train, getting getting everyone to pack up their gear
(05:40):
and getting their vans and follow the police car. Just
as they're about to move off, and this is in
late at night and the pitch black there, Ryan's come
out of the shadows and calling out the police and
threatening to kill them, and it ended up in a
chase round a van and taser was deployed and then
(06:01):
eventually Ryan was shot before and he had a laded
cross aimed at the police. Absolutely horrendous circumstances. I compiled
the brief of evidence and provided to you as a coroner.
What's your takeaway from a situation like that? Because no
one wins, a person's lost their life, but the people
(06:23):
have been terrified by witnessing what had occurred. What's your
takeaway from an incident like that?
Speaker 2 (06:30):
Well, I think there are a number of takeaways. The
first The first thing is, obviously your life has been lost,
and in this particular case, there were tragic elements of it.
Ryan lost his life because he threatened the police and
(06:52):
they acted in self defense. But whether he was mentally
sound or not, you'd have to you'd have to doubt
it'd been dabbling in drugs and so on and so forth,
and so that said something sad about his life. I
think his father I remember being very affected by Ryan's death,
(07:13):
but not angry so much as sad, and I felt
really sorry for him, and of course for the extended
Prinkle family. The Prinkle family has to live with Ryan's death.
But unusually, the police here were almost victims themselves, and
(07:39):
I can't imagine how terrifying that must have been, to
be honest, to have someone hunting you with a crossbow,
as you said, pitch darkness, armed only with tortures and
so forth, and the torch, of course, could show show
Ryan where you were as much as possibly illuminate him.
(08:04):
So an incredibly frightening situation. And then the police were
trying to protect a whole gaggle of people who were
simply there for a good weekend and so forth. They
were ordinary country police, you know, just decent people trying
to protect members of their community and suddenly they're being
(08:27):
hunted for their lives.
Speaker 1 (08:28):
Well, the way you describe it them referencing the movie
Deliverance had that feel about it because they were being
hunted and he was calling out, addressing camouflage gear, making
threats against them, asking all the other people to join
in and kill the police. It was something that was surreal,
(08:49):
and I remember part of my role as a critical
incident investigator that I had to interview the police involved,
and I thought that very professional, but it was traumatic
listening to them recount what had happened, and at no
point they could shine their torch, but then they'd have
(09:09):
to turn their torch off because if they're shining their
torch trying to see in the dark where he was
coming from, they potentially made themselves targets exactly, and they
did everything they could to avoid the confrontation and all
the warnings and literally running around the van with him
chasing them. It was just a horrendous situation. And then
(09:32):
add to it, and I think it gave me a
lot of respect for what country cops do, Like there
weren't there wasn't any backup for them, the communications. It
was an hour or two before other police came by.
You've got the other people in the situation. Someone's just
been shot and critical injuries and they're left there dealing
(09:54):
with that. I think Carter told me he wasn't sure
if the rest of the community were going to attack
him after the shot, and he thought that might be
so just a horrendous situation.
Speaker 2 (10:06):
Very horrendous and very courageous of them. Yeah. Well, one
of the recommendations that came out of the inquest was
that they'd be awarded some sort of gallantry metal accommendation,
which I think they received later on.
Speaker 1 (10:24):
Yeah, they did. Know. I've seen a lot of things
in policing, and that was one that was right up
there because they didn't have to stay. They could have
just driven out, but they were protecting the public in
classic what police should be doing, and putting their own
own situation at risk and doing that. There was in
(10:45):
all the darkness you do see some humor, and the
people that you would expected a gathering of the Moon
Festival or whatever on the School of Happiness Farm were
an eclectic group of people. There was one I can
say this, I don't think he'd take any offense. I
think he'd be proud of it. There was one particular
person that was a witness to this situation that he
(11:08):
didn't believe in wearing clothes. Clothes just weren't his scene.
And I don't think you realize, as the deputy state
coroner how much work we had to go do behind
the scenes to get that witness to appear in court
with some clothes on.
Speaker 2 (11:24):
I didn't know that.
Speaker 1 (11:25):
We explained that, you know, it's probably a situation where
you should wear your clothes, but I don't believe in clothes. Man,
not my scene. I think we convinced him that we're
a pair of shorts and a singlet. That's as close
as we could get him. But he was itching because
he just didn't like clothes. And I think there was
another witness. I don't think it was that one that
(11:48):
when he was being sworn in, and I'm not saying
this verbatim, but it was pretty much along the lines
of what is your what could you please tell us
your name? I don't have a name, I'm an entity,
and then produced a piece of paper from his pocket
and produced that. And you handle it very well as
a coroner.
Speaker 2 (12:10):
I knew I was dealing with some interesting characters.
Speaker 1 (12:13):
Yes, well, and the hippie bus. We had to find
a place that he could park the hippie bus that
wouldn't be stolen. There was all sorts of behind the
scenes work that you just don't understand on that and
we're laughing about as a tragic situation. But something that
when we talk about the emotion of a matter like
that is Ryan's father acknowledging the police, not blaming the police.
(12:37):
And I thought that was that was a really moving
moving part.
Speaker 2 (12:41):
Yeah, he was. He was very gracious and very stoical.
Clearly quite a well known person because he was a
well known footballer and it must have been a tremendous
blow to him to lose his son, but also some
degree of humiliation, I think, Yet he was. I thought
(13:04):
it was quite noble, really he was.
Speaker 1 (13:06):
I stayed in contact with him and had a few
communications with him, and he was very pragmatic about it.
He was suffering from the loss of his son, but
he understood the situation that it was probably inevitable what
that was going to be the end result with how
his son's actions were. But yeah, it was a strange one,
but they're the type of things and I want to
(13:29):
speak to about critical incidents because people don't fully understand
the role of the coroner in a critical incident. Critical incidence,
when we refer to that in policing, is where during
the police operation someone's lost their life, and that might
be a police shooting or a car chase. Critical incidents
are set up as a homicide detective. If someone's been
(13:51):
shot by police, there'll be a homicide inspector heading up
the investigation. Then we have to present the matter to
the coroner. There are always cantentious issues. What's your thoughts
on the way critical incidence are handled well?
Speaker 2 (14:06):
One large I thought they were handled pretty well. One
of the classic criticisms of it is that New South
Bale's police are investigating New South Bal's police. In some
other jurisdictions you have police from other you say, police
(14:27):
forces or whatever. I think ideally would have independent another
independent police force doing them. But coroners are meant to
be the people who provide the independent oversight and providing
and I think it in practice does work pretty well
(14:49):
because coroners are also assisted by people from the Crown
Solicitor's Office, and then there's in police cases as usually
a barrister from the independent bar very often a silk
who is independent. They have an ethos of independence, and
(15:12):
some of the council assistant I've worked with have been
really quite rigorous in demanding from the police investigators that
they do various things, or investigate various questions, or make
various inquiries. So I think in practice that works pretty well.
(15:35):
But that said, there are people who, no matter how
well it actually works in practice, are suspicious because it
is New South Bale's police carrying out the critical incident investigation.
I know in the parliamentary inquiries in New South Bale's coroners,
(15:58):
I think it was the Jumbunner Institute, which is an
institute at University of Technology. It's an indigenous research group
made a submission that coroners were captured by police. And
there's a concept of regulatory capture that the pop you're regulating,
(16:23):
the regulators are regulating, capture the inspectors or the regulators.
So the argument was, unless you had an independent police
force doing the investigations on behalf of coroners, that the
New South Wales Police Force would basically possibly potentially capture
(16:45):
the coroners. And so that you know the police and
the coroners would think alike, that's psychologically possible, but where
do you get the independent investigators.
Speaker 1 (16:57):
That's I've got a got thoughts on critical incidence because
a large part of my career is spent tied up
on critical incidence, and I could be in the middle
of a murder investigation, a critical incident would occur and
that got priority. My frustration was the amount of time
I was spending on critical incidents when I'm in the
(17:18):
throes of a homicide investigation. But that's just from a
resourcing point of view. I think a perception is the
most difficult thing to overcome. The families and many a
time I've introduced myself to the families as I'm the
person ever seeing the investigation into the death of your
loved one, and the initial response police investigating a police
(17:43):
because there's anger and we're making the introductions fairly early.
There was always anger and a lack of trust. And
I've got to say, in defense of the police or
my observations of the critical incidence that I've been involved in,
whether I'm leading it or working on it, there is
a degree of independence where that's why they bring the
(18:03):
homicide in and part of the process. For someone on
the critical incident, you're not allowed to know the police
or not to have a connection with the police involved
in the incident, and that would discard you from the investigation.
So I think there is a degree of independence, but
I think everyone would be better off if we did
(18:25):
have someone else to investigate it. And there's a lot
of oversight that goes into place. We have professional standards
overside in the work that homicide are doing. Is independent
officers just a thought I always and I tried to
sell this when I was in the cops. I'm sure
I'm not going to be able to sell it now,
but let me try one more time. You need the
(18:47):
skills to investigate the death of a human. Homicide detectives
have got those skills. I always thought the way a
critical incident could be run is that homicide get called
out for the first forty eight hours and make sure
the crime scene is preserved, witnesses, identified, lines of inquiry,
all the things set the investigation up. Then you could
(19:08):
bring in other people independent to come in and complete
the investigation. So homicide are basically just setting the investigation
up in a direction, and then that independent body because
you can't have in the state police coming in because
it takes too long for them to get to the scene.
So you've got to have people be able to respond.
Homicide is set up to respond twenty four to seven
(19:30):
at short short notice homicide there and then perhaps police
from interstate or a different the investigative body because you've
seen it. I know you've seen it. We've been speaking
to people that have that view. They won't be satisfied
that police are investigating investigating police.
Speaker 2 (19:49):
Yeah, that's right, and I think that's hard on the
people who the police officers who do a really thorough
investigation fair number of critical incident in quests, and only
on a couple of occasions was I a bit doubtful
(20:09):
about or did I have any doubts really about the
quality of the investigation or the initial quality. And by
and large those problems will solved because I would have
a confidence with my counsel assistant and solicitor and we'd say, okay, well,
(20:33):
detective so and so it doesn't seem to be thinking
about this or that, or maybe you know, hasn't hasn't
explored this issue or something, and then we would and
under the coroners Act. You can actually direct police to
do various things. Don't like, you know, pulling rank in
(20:54):
that way if you get cooperation. But if you need to,
you can do that. I prefer to say it as
a as a partnership. But a couple of times, in
a couple of cases anyway, council assisting said to me,
I don't you know, I think we need to get
the whip out and give me a bit of a
(21:16):
tickle up or something like that.
Speaker 1 (21:18):
I don't think it hurts that there's a safeguard if
something's missed now, whether it's through laziness and competence.
Speaker 2 (21:24):
Or just usually busy.
Speaker 1 (21:27):
Yeah, well that was that. Yeah, I started off talking
about it. My gripe was I've just been in a
homicide of a critical incident that was priority because higher
up the police realize that there's going to be criticisms,
so we're going to say, well, we've got the people
with the appropriate skills investigating when the death has occurred
(21:48):
mental health factors that come into police students, because time
and time again I saw that. Have you got any
thoughts on that? I know on the back of the
Courtney topic inquest, there was a lot of recommendations about
police training for mental health.
Speaker 2 (22:03):
Yeah, I've actually participated a couple of times with LEASA
topic Courtney's mum in talking to police about all of
those scenarios. Incredibly difficult. Ideally, what you'd always have if
(22:24):
someone is psychotic in some way, you'd have a mental
health team who possibly would be escorted by police, but
the mental health team would be the first responders rather
than police, I think. I mean, it's very very difficult,
isn't it, when police, who are very often very young,
(22:49):
are the first responders to people acting dangerously to themselves
or others. And I've seen this happen. I've seen police
training where you know, people have shown how to back
off and various techniques for trying to talk people down
or keep them corraled in a safe space. But sometimes
(23:14):
you run out of space, and then it's and then
it can be a question of basically self defense. And
I know, well, certainly I've done cases where police have
shot people just too I think, and they were certainly
in self defense, but they're shattering for everybody afterwards.
Speaker 1 (23:42):
Well, I haven't seen a police offer so that it's
been involved in a shooting incident, hasn't been affected. It's
as much bravado that can come up after shooting incident
and police know I'm fine. It does have an impact.
There is consequences.
Speaker 2 (24:02):
There are consequences, and I think you know, everybody knows,
everybody who's involved in these things knows that was another
human being, yeah, just like me. And they've got a family,
and they see the family at the inquest. Personally, I'd
like to see lawyers who represent police officers and the
(24:23):
Police Association try to persuade cops who involve police that
turning and facing the family and apologizing yeah, might be
a good thing for their own mental health.
Speaker 1 (24:40):
It's interesting you say that I'm not going to talk specifics. Well,
I've seen cases like that. It's almost if you talk.
There is that little bit of adversarial in the inquest
and a critical incident, and I see police react like
they want to just break down and cry with the family,
and it would be benef official for everyone involved, But
(25:02):
there's a sort of a stoic front that no, we're fine,
we're just doing our job. And I've heard police in
the witness box saying, look, I ran an operation where
someone was shot and killed, and I acknowledged that, and
I was being cross examined about well, it was a success,
(25:22):
wasn't it, And I've said, no, it couldn't be further
from the success. I'm devastated by it. That was my
true belief. But I've seen police that I think anyone
would be of that view stand there and try to
put on the brave front. No, they got what they deserved.
My life felt threatened, and it just aggravates a family
traumatized as a family, and I'm sure it traumatizes the police.
(25:44):
So yeah, and I think sorry, I think it is
part of the legal advice. Don't don't concede anything here,
and you did the right thing, but you can show
emotion and still do the right thing.
Speaker 2 (25:59):
Yeah, and even if you did have to act in
self defense, and in most of those cases that's exactly
what happens, you can say, yeah, but I really regret
doing this, and I can see how affected you are.
(26:21):
Kirsten Edwards said, I'm sure you've come across an in quest.
Very very good barrister who I think has sometimes represented
police in in quests told me about a case in
which she had seen a young cop break down in
tears and say something to the effect that to the family.
(26:44):
I think about your son every day of my life,
and if I could go back and prevent this happening,
That's what I'd love to do. And the family, the
family I think probably wanted to see his pain, not
just feel it themselves. And having and Kirsten Tommy that
(27:05):
having seen him breakdown like that, they were much more
willing to accept what had happened, to forgive him and
to see him as a fellow human being. And if
we can see one another as fellow human beings instead
of them and us always you know, you're the other,
(27:28):
I'm the strong one, I was just doing my duty
or whatever. I think we go a long way to
making these increase a very traumatic for everybody, but we
would do a great deal to reduce the trauma that
they cause to people, families, police, correctional officers, whoever. If
(27:53):
we could show that, if witnesses could show that they
they are her to I think it would be really
good if we could get inquests on more quickly, because
I think the longer that the time lass. But yeah,
it does. And people not only come up with their
(28:14):
own theories of how this death came about, which can
be can be right, but very often wrong. That can
be very difficult for people's mental health as well. But
I think I think there is a I think in
grieving psychologically, there's a sort of a sweet spot. You
(28:38):
need some time to get over the initial impact and
then you can think about what actually happened, and if
you if you can hear from the people who were
involved what happened at that moment. In that sweet spot,
then I think you are more likely as a as
(28:59):
a fan only of someone who's died, or as someone
who was involved in the incident, the fatal incident, maybe
even the person who caused the death, I think you're
more likely to come up with some chance of healing
in maybe not immediately, but over time.
Speaker 1 (29:20):
Well, what you're saying there are words of wisdom, and
I suppose that comes from seeing the emotions as rule
as it is for as long as you did in
the environment. It's confronting. But what you talk about, I
think we could encapsulate that in the word of just
bring some humanity to it.
Speaker 2 (29:39):
And I mean, I'd like to think that the Police
Association and the Public Service Association and those sort of
people with the unions would say the benefit of this too,
because sometimes I think thinking legalistically is not necessarily the
(30:00):
best way to think about these things.
Speaker 1 (30:01):
Yeah, and that's exactly how it's approached from the police
point of view, and there's so many more layers to
it than just from a legalistic point of view. Another
thing that sounds counterintuitive when I say this, but mental health.
And we talked about how that could be navigated if
there was someone there with the expertise when police respond
to those type of jobs. But I'm concerned. I'm saying
(30:24):
this now as a former police officer, but seeing what's
gone on the lack of training, tactical training. Now we're
trying to reduce police shootings. Tactical training is not just
pulling out a gun and shooting someone. It's been comfortable
in the environment, knowing how to handle yourself, knowing how
to de escalate confronting situations. Police are entitled to use
(30:47):
their firearm if they fear for their life. If we
could train people, train police with more training. Now I'm
not sure I've been out for years now, but the
amount of training days, tactical training days we do, I
think it's one a year, like you have a shoot
once a year. Now, I was involved in tactical policing
(31:07):
where we had to shoot the minimum once a month,
and it was just so it became repetitive. You felt
comfortable with your weapon from when I joined the police.
And now what the young police are carrying these days,
with the tasers, the OC spray, of the expandable battern,
and they've got so many other things. It's complicated in
(31:28):
a time of stress, how they're going to react. I
just think we need to and I know there's a
cost associated with training police, but we need to dedicate
more time to training.
Speaker 2 (31:40):
Yeah, well that doesn't surprise me you say that, because
almost always in these inquests, the question of tactics comes up,
doesn't it. And you often find that when you boil
it down, some of these deaths are ventable and they
(32:01):
could have been prevented had better tactics being employed. So
you know, there's training days that I've been up to
see how participate in with lesser topic. Police have shown
videos of how to retreat from a dangerous situation, et cetera,
et cetera, But how well does that actually work in practice?
(32:25):
And I quite often think about a particular case, this
is ut in Western News, South Bales I won't use
the man's name because he was an Aboriginal man, but
he was shot and killed by police or a police officer.
The police officer was acting in self defense because the
(32:46):
Aboriginal man had attacked him with a club block. But
there'd been an earlier incident. The police were looking for
this man and they suspected he was in a house.
And I sometimes wondered how good a job I did
(33:06):
as a coroner, because although I had a very good
counsel assisting, one of the questions that I later thought
about was the tactical issue. The police entered the house
thinking he may be inside. They entered the room and
this man was in there, and the officer pulled out
(33:26):
his taser and tasered the man that had, as far
as you could see, no effect on you except to
mak him even angry. He had this club like instead
of whacking the officer around the head and shoulders, and
the officer managed to get his gun out and went
bang bang. Now had the police what I now think
(33:48):
is and had we asked for more expertise on tactics,
you know, could the police have tactically secured that house
better discovered whether or not the man was in the
house before they actually entered the room he was in.
(34:08):
I don't know the answer to that, but I kicked
myself quite regularly when I think about this, for not
having at the time raised the question. In the end,
we walked away. I'm sorry, you know, terribly sorry. The
man's father was there. There was a group of Aboriginal
people who were very angry, you know, and they saw
(34:32):
it as just another day in the colony, I guess
something like that. They could not accept that this death
had come about through any thought of anyone except the police.
And I thought, if I now think, if I'd done
a better in quest, it may have made absolutely no
(34:55):
difference to the community, the Aboriginal community. We would have
got a better answer, I think, and we might have
been able to we might have come up with the
recommendation that would have made this sort of situation safer
in future.
Speaker 1 (35:13):
Well, there was a police shooting and going back a
very long time ago where tactically it became more contained
than negotiat rather than going in with the tactical teams
the active shooter scenarios. Now that's had to be adapted
for current times and the threats. But yeah, I don't
(35:34):
think you can get enough training in that type of
the type of situation, and you are reacting in what
could be the most stressful situation that you've you've encountered,
and you need to be able to think clearly, and
that only comes through with training. I think it's something may.
Speaker 2 (35:51):
Only happen once in your life. Yes, please, I've said,
but if you can't react instinctively, instinctively in the most
appropriate way, can I tell This reminds me of a
case that amused me. Actually it didn't, it didn't have
a terrible ending. And that happened while I was a magistrate.
(36:14):
To police go to go to the door of the house,
the knock on the door, they said, please, please, you
open the door. Anyway, they opened the door and a
guy comes rushing down the hallway waving a samurai sword
and the police officer, I was a magistrate, not a
coroner at that stage. That the guy was charged with
(36:37):
dangerous weapon or something like that. Anyway, the police. What
amused me was this police have a funny way of
writing statements. So and one of the ways they write statements,
so that must be taught this in the academy. Is
you don't say. I said, blah blah, you say. I said,
words to the effect of and this police office. I
(37:00):
said something like I saw a man running down the
hallway waving a samurai saw it. I said, where's the
effect of fuck retreated? I said, words the effect of
police Please, we're under arrest. He said, fuck off.
Speaker 1 (37:22):
I've seen statements statements like that. But yeah, there's training
and something stick. But yeah, I see the funny side
of that. I want no names, no pack drills. But
I went back as a crime manager and there was
a young officer and just needed educating, and she was
trying to do things properly. She's given a statement, and
(37:45):
I had to go through the briefs of evidence and
look at the brief of evidence, and someone brought that
to my attention that hey, boss, can you have a
look at this evidence of all this brief I've got
some concerns, and basically she's gone. I think it was
a domestic situation a I don't say domestics minor, but
it was a rather minor thing. And she's communicating in
(38:06):
a level that people would understand. She's going, well, this
is the police officer. So I said, what the fuck
is going on here, and she said, nothing, you bitch.
Don't you call me a bitch, You're the bitch, and
like that, like that, And so I got her in
to my office and I said, look this statement. I said,
I'm a little bit worried about the wording here. And
(38:28):
she said, we were told in that we've got to
say exactly what was said. And one hundred percent I agree,
it's got to be a true account of the conversation.
And so I decided to approach it a different way.
Maybe as a police officer, we shouldn't swear so much,
like you that's what said on this occasion, But maybe
next time you're speak to a member of the public,
don't throw in so many swear words. But yeah, it's
(38:50):
all a learning process, isn't It is a learning process,
And I feel, you know, I look back at the
mistakes I made in the cops when I just got
in and yeah, I don't know how I got through
it half the time.
Speaker 2 (39:02):
Well, fortunately, coroner's mistakes don't end up with anybody getting
hurt or yeah.
Speaker 1 (39:09):
Yeah, well that's the thing. So we've covered off on
like critical incidence, and that was a a lot of
my time in coroner's courts were put through overseeing critical
incidence other cases that you've been involved in the death
of fourteen people at Quakers Hill nursing home fire. That
(39:29):
was a horrendous situation. Do you want to tell us
what your involvement overseeing that inquest? Because it was a
person I think he's Roger Dean was convicted of eleven
counts of murder.
Speaker 2 (39:42):
That's right.
Speaker 1 (39:43):
So this situation has happened, the fires were lit, the
people at the nursing home were killed. Homicide have investigated,
he's been charged, he's been convicted. What role did you
have as a coroner in that situation?
Speaker 2 (39:58):
Well, Conner has always had have a role to look
at homicide cases and these were obviously this is a
mass murder. But the reason we could have decided not
to do an inquest, this came after the murder proceedings
were over. The reason we decided to do it was
(40:21):
for a couple of reasons. One was, was there anything
that we could look at about the management of the
nursing home in relation to use of drugs or security
of drugs because Roger Dean was doctor shopping. He has
drug affected and the reason he started the fire was
(40:43):
to prevent the management of the nursing home finding out
about his stealing of drugs schedulate drugs. So he wanted
to cover up his tracks, and he was reckless. He
didn't particularly want to kill people, but he wanted to
cover up his own wrongdoing, so he set these two
(41:07):
fires and then he ran away turned up later while
the fire was being fought. Were also interested in the
response of the fire brigade of how the people were
evacuated from the nursing home, whether there were any lessons
(41:29):
to be learned about the particular fire, how it's been
responded to, the building codes, the actual fire hydrants, and
those sort of things, because there had been some difficulties
with various aspects of connecting the fire appliances to the
(41:51):
water supply and so on and so forth. So I've
forgotten how many recommendations we came up out of that.
It was a significant number. And one of the main
things that in the end we didn't have to recommend
because it came out of the case was a change
(42:12):
of the building code to require that sprinklers be installed
in all nursing homes, because sprinklers can reduce the ambient
temperature in a very hot fire enough to save lives.
These sort of fires can get up to incredible temperatures,
(42:33):
you know, six hundred degrees one thousand degrees centigrade because
they're burning lots and lots of petrochemical materials. Sprinklers can
bring it down to a couple of one hundred degrees,
at which point people can be rescued, you know.
Speaker 1 (42:50):
Okay, so that's what It's not just saving the building.
Speaker 2 (42:55):
It's saving the people is the main thing. The building
could be, but the people could be saying, yeah, yeah, do.
Speaker 1 (43:02):
Those recommendations that get followed up where they follow up.
Speaker 2 (43:06):
And they were most of them were. The fire was
far and rescue are really good at following up recommendations
and in fact, they make a really good contribution to
framing recommendations for coroners.
Speaker 1 (43:24):
Well, it's important, like the magnitude of yeah, an offense
where it's taken for their lives. It was horrendous that situation.
Some of the strange deaths you've seen, and we're not
making light of light of death. Every death, you know,
carries a weight and the impact. But what are some
(43:44):
of the things that you just wouldn't anticipate that's left
and the lasting impression on you.
Speaker 2 (43:48):
Well, one was, and this was very early on in
my time as a coroner. An elderly man was walking
his dog outside Royal and So for hospital, and somehow
he got tangled up with the dog, I think, in
the lead, and he tripped over and he broke his
(44:10):
fema and he ended up in hospital. Unfortunately, he died
of pneumonia, and because it had an accident, his death
was reportable to their coroners. Well, I became hyper vigilant
after that when I was working my dog and walking
my dog, and if anyone came near me with the dog,
(44:32):
I was very, very cautious of it. I became less
hypervigilant and more fatalistic. I guess after about a year
or so.
Speaker 1 (44:44):
But you and people stopped reporting this strange man telling
the careful when they're walking their dogs.
Speaker 2 (44:51):
Oh yeah, so I think I became less strange over time.
Speaker 1 (44:55):
I can imagine like things like that that you just
never anticipated and okay, it sort of sticks with you
for whatever reason.
Speaker 2 (45:02):
Yeah, there are others, but I think I prefer not
to describe them.
Speaker 1 (45:05):
Okay, fair enough. You explain in part one why you
left left as a coroner, and it wasn't by choice,
It was just your time to leave as a coroner. Yeah,
since you've left the coroner's court, clearly you haven't. It's
like me, I've left homicide and I'm hosting a podcast
called thy Catch Killers. You have left the coroner's court
(45:26):
and you're doing a PhD as cornial matters.
Speaker 2 (45:30):
That's right. So, even when I was working at the
coroner's Court, I really felt that the system could be
designed and structured and resourced a lot better than it was.
We used to be quite proud of ourselves, you know,
proud of the individual work that we did and so
(45:53):
on and so forth, but most of us didn't have
the opportunity to think much about how the system worked
as a system. And as I was saying right at
the beginning of the podcast, Gary, it's a multidisciplinary system.
It's not just coroners. It's not just coroners telling police
(46:14):
to do that or forensic pathologists to do this. It's
a group of people all trying to investigate deaths in
the hope of either finding lessons or at least giving
people answers. And I don't think we do it especially
well in New South Wales. The system we have was
(46:37):
it's really more or less the same, except on a
larger scale than it was in the early nineteen hundreds
when the magistrates took it over. It's still run by
the magistrates. We have better systems in Australia. There are
better systems overseas.
Speaker 1 (46:53):
I've heard you say that you rate Victoria as one
of the best. Yeah, what is it about Victoria that
sets on the side.
Speaker 2 (47:02):
Well, Victoria, Well, a few things. First of all, it
was built around a concept or two concepts really, the
two concepts being one care for families. So everything that
coroners do and the coronial system does in Victoria has
(47:22):
to take into account the effect on families and their distress. Secondly,
it was all about the second thing is the second
pillar is prevention of future deaths. And in two thousand
and eight the Victorian system was reformed from top to bottom. Well,
(47:43):
for many years that had the idea of trying to
make it more effective at preventing future deaths and injuries,
but the system itself was pretty ordinary, and in fact
they had a parliamentary inquiry in two thousand and six
which flowed from complaints being made by families about how
(48:04):
slow it was, how inefficient it was, et cetera, et cetera.
We have exactly the same sort of system as the
Victorians had pre two thousand and eight. It's not efficient.
The people who work in it are really good people,
but they're not resourced well. The system isn't structured or
(48:25):
designed to be effective or as effective as it could
or should be. It's not very good at preventing future deaths.
We only hold one hundred inquests a year, and the
only way coroners in Byales have any illegal right to
make recommendations to prevent future deaths is if you hold
(48:47):
an inquest. Well, if you don't hold an inquest, there
are no lessons disseminated to the community. There's a lot
of data collected and that's sent to a national database
in Victoria called the National Coronial Information System, but that's
mainly used by university researchers, not so much by coroners,
(49:12):
whereas it was set up to help make coroners work
really effectively. The Victorians have an in house research group.
Ontario has an in house research group. I think Nova Scotia.
Speaker 1 (49:26):
No, okay, this is from all your overseas study.
Speaker 2 (49:31):
But in New Zealand's looking at it so News up
Wales has had two parliamentary inquiries in the last three
years or four years which have recommended radical reform. And
basically the reforms being recommended are we set up a
specialist court, well resourced with in house researchers, whose job
(49:58):
would be to try to come up well first of all,
identify patterns of patterns and trends of fatalities, which could
then be fed to public health and safety authorities to
try to save lives. And I explained before not only
is there an enormous, an incalculable human cost to sudden
(50:24):
and unnatural and unexplained deaths, but there is also an
economic cost. If we could if we could make the
coronial system in news up Bales even slightly more effective,
we could save some lives and the money saved the
economic savings would pay for a new system. The News
(50:47):
Out Bail system costs around about eleven million or twelve
million dollars a year. The Victorian system costs around about
twenty seven million dollars a year. That's its compared with
what we spend on health, police, public safety. Generally, you
can have a much much better system for not very
(51:09):
much more money.
Speaker 1 (51:11):
It does seem like peanuts on the scale. It is
peanuts because a constant complaint I've had dealing with victims
families is the length of time before the matter becomes
and they're hanging there almost in a state of suspense,
waiting for this matter. And exactly if I'm saying in contact,
(51:32):
all the inquests that set down for next year, it
was going to be this year, but it's been put
off for this reason or that reason that needs resourcing,
like we need to be able to get the turnover
done quicker, would you?
Speaker 2 (51:44):
I absolutely agree. I did some research recently for an
article I wrote. I looked at all the published coronial
findings for twenty three and twenty twenty four. My PhD
about forty percent of inquests took more than three years.
(52:06):
It's now it's over fifty five percent.
Speaker 1 (52:10):
Now how that break break those figures down? Fifty five?
Speaker 2 (52:13):
Fifty five percent of inquests take more than.
Speaker 1 (52:17):
Three years to get finalized.
Speaker 2 (52:19):
To get finalized, and more than forty percent take more
than five years. Imagine having to wait that long. I
have a barrister's practicing certificate now and I'm representing a
man whose mother died in Orange hospital in twenty twenty
one and we still haven't got a date for an inquest.
(52:43):
Were nowhere near.
Speaker 1 (52:44):
And he is that because of the availability of a
coroner and availability of the court.
Speaker 2 (52:48):
Well, it's for all sorts of reasons, the investigations taking
a long time, or all sorts of reasons, but there
is a tremendous need not just for more resources, but
for a better way of coordinating these various arms of
the system. Michael Barnes, a former state coroner, at the
(53:11):
parliamentary inquiry in twenty twenty one, gave evidence and he
said words the effect of this system is so uncoordinated
that it really is a bit of a joke to
call it a system at all.
Speaker 1 (53:30):
Pretty DAMMI. And this is Michael Barnes who came down
from Queensland.
Speaker 2 (53:34):
Michael Barnes who came down from Queensland, who's now the
new South Wales Crimes Crossia. Michael. Michael really knows all
about coroners and coronial systems. He has seen most of
them around Australia. He's provided advice to many of Australian
(53:55):
and I think New Zealand coronial systems and other places.
So Michael is one of the Australia's leading experts. He
knows when he says the system not working, well.
Speaker 1 (54:06):
Well we've got to get we have got to get
it better. Haven't we like it? So I know the
trauma that causes families with delays.
Speaker 2 (54:15):
Look, I believe the Attorney General has his heart in
the right place. And the problem, of course, as it
always is, is resources and that means government money, and
that means priority. There is always enough money. The question
is where does this idea, this concept of a really
(54:38):
good colonial system sit in the order of priorities. And
it doesn't sit, in my opinion high enough. It's time
it was improved and radically overhauled.
Speaker 1 (54:51):
There's six things and this is in the article that
you're the author of. So I suspect you'll agree with
the things. Six things that need to be done to
build a modern coronnial system for New South Wales. If
I could just reimprovement, then we can discuss if you
want to one define the philosophy and purpose of the
(55:11):
coeronnial system in terms of respect and care for families
and prevention of death. I think we've already spoken about
that that was what the whole philosophy. What's it there for.
Speaker 2 (55:22):
To show recognition and respect?
Speaker 1 (55:24):
I believe, okay. Point number two rewrite the Coroners Act.
Speaker 2 (55:30):
Yeah, the Coroner's Act is out of date. It's just
a Victoria. New Zealand. Other places have much better acts.
It's so obvious a thing to.
Speaker 1 (55:39):
Do, okay, So, and that's just making it more contemporary.
The things that need to be changed work better. O
Number three. Create a specialist Coroner's Court to conduct all
coeronnial inquiries and coordinate the multidisciplinary system.
Speaker 2 (55:55):
Yeah. Well, at the moment, cases that occur in the
country are reported to LIDCOLN with the specialist coroners work
Someone has a look at the case and then it's sent.
In most cases, it's sent back to the country magistrates.
The country magistrates are not specialist coroners. They don't have
(56:16):
the resources, they don't have the training, and they don't
have the experience, and yet they're asked, on top of
their very busy criminal and civil loads, to look after
forty five percent of the state's coronial workload. It's ridiculous.
Victoria got rid of it years ago. New Zealand got
(56:38):
rid of it even earlier. Every single Australian state and
territory now confines coronial matters the coronial jurisdiction to people
who are specialists in that jurisdiction.
Speaker 1 (56:53):
Well, I got to say, you've seen here listening to
your talk and seeing how you went about your business,
and the coroners that I've appeared before, the experienced coroners,
You've got so much I call the wisdom but understanding
of what's needed in the coroner's court from the experience
that you've got. So it makes a lot of sense.
(57:14):
Point number four. Focus the system on prevention of death
by developing in house research capacity and connecting with other
public health research institutions.
Speaker 2 (57:23):
Yeah, this is what I'm talking about with Victoria. Victoria
transformed coronial practice really and everyone around the world involved
in the niche world of coroners knows this. Victoria led
the way. It's got some of the leading thinkers about
coronial practice. In Freckleton is probably the leading thinker in
(57:47):
the world is a Victorian barrister. David Rampton is a
Victorian forensic pathologist, and they are two of the leading
thinkers in in the world on this and both of
them have the concept of coigners as public health and
(58:08):
safety officials, and that means trying to prevent future debts,
looking at what the data are telling you. Instead of
taking samples of one one case or cases one at
a time and think, oh, yeah, I've got the answer
for that, why don't we look at cases and group
them together and look at what patterns and trends are
(58:29):
telling us, and then say, what lessons do we learn
from this? How do we stop this pattern or trend recurring?
And that's why I'm saying that the excuse of governments
always is we can't afford it. But if you invested
in research like that, or linked up as partners with
(58:53):
University of researchers to do this kind of research, the
savings would be so honestly incalculable.
Speaker 1 (59:02):
You're countering any arguments about what we need the funding.
You're saying, well, look at the model we're talking about.
It would be fiscally responsible.
Speaker 2 (59:11):
Do they And I've been talking to the news Outdal's
Health about this and they can see that the issue,
and I believe the Department of Community, Communities and Justice
does too. It may be that in the next couple
of years someone will say, oh, yes, it won't cost
very much and this is the bang for the buck
(59:35):
we'll get out of it. It would be a big
bang for not very many bucks.
Speaker 1 (59:39):
Okay. Point number five. Expand the resources and streamline the
processes of the system to reduce delay. I think we've
already we've touched and discussed that, and I see the
trauma that causes family, so I think that's something that
needs to be done the delays.
Speaker 2 (59:59):
Could I just so about that? But here's an obvious thing. Victoria,
almost the same number of deaths reported every year, has
fourteen specialist coroners. New South Wales at the moment has seven.
But I'm told that two of those coroners are going
back to the local court to work as general magistrates
(01:00:21):
in September. I hope that doesn't happen. I hope. But
even so we've only got seven.
Speaker 1 (01:00:27):
The disparity disparity.
Speaker 2 (01:00:30):
Queensland has ten and they have two thirds of the
workload of New South Wales New Zealand, but half the
workload of New South Wales has twenty six. So New
South Wales's government is doing coronial work on the cheap.
It's not saving the lives the number of lives it
(01:00:51):
could do if it invested in the system. It's putting
off the evil day.
Speaker 1 (01:00:57):
It's it's the important thing too, isn't it about saving lives?
Speaker 2 (01:01:01):
Ye professional lives, and it's all about carrying the families.
You know, if even if we held more in quests
and had more coroners, but you didn't hold them for
five years or three years, you might ask, what's the
point of holding it an inquest in four years time
if the impact by then will have dissipated. You need
(01:01:25):
to hold in quests within the first couple of years
after someone started. If you're going to learn the lesson
and have real impact, I think.
Speaker 1 (01:01:35):
I think you're one hundred percent right point number six.
Minimize unnecessary extra trauma for family members by making inquest
processes more restorative and less adversarial.
Speaker 2 (01:01:47):
Yeah, look, I don't think all in quests can be
non adversarial. But I in Ontario back in the nineties,
they had this idea of around table kind of a conference.
I don't know if you're familiar with the restorative justice anyway.
Restorative justice means that people who have done something, who
(01:02:08):
have caused a harm, meet the people who have been harmed,
and I think we could have a very different kind
of coernial system if that became the one of the tools,
one of the methodologies where we brought people from hospitals
and families together, or from prisons and families together, or
(01:02:34):
police and families together, or whatever it may be. Accidents
people have caused accidents and families together, because as we've
explored in this conversation, very often it's not due to malice.
Most often it's not jueitimalice. You know, homicides are very
(01:02:55):
small proportion of all these deaths. It's mostly accidental or
something of that nature, or a mistake. If people are
willing to meet and open their hearts to one another,
that I think could be or could have, but not always,
(01:03:15):
but it could have in many cases a very restorative
healing effect. It's not closure, but it could enable people
to go on with their lives in a happier, less
troubled way.
Speaker 1 (01:03:33):
Well, I'm a big advocate for restorative justice. From what
I've learned and seeing with people that come in here
and lessons that can be learned from it, I think
it's something that could be introduced into the cranial sphere.
Speaker 2 (01:03:47):
Yeah, well, if I stay current, that'll be one of
the first things I do. Really, I really would.
Speaker 1 (01:03:54):
And there's one more point. I think we're talking off
a camera that if there's how many cases are reported
to the coroner and New South Wales on average a
year six just.
Speaker 2 (01:04:05):
A bit under eight thousand now and when I read that,
it was about six.
Speaker 1 (01:04:09):
And six and a half from to three years ago,
so about eight thousand now. And we're saying we're talking
about the figures that equates to eighty thousand because of
there'd be ten people that's been impacted on by someone's death,
so and it might be twenty, it might be twenty,
so hundred and sixty thousand people. Look, it's something that
(01:04:30):
what we've talked about, the whole coronial process, it's very
close to my heart because I've seen the pain. I've
seen what's gone on and the work that happens. Ask
you a question coming to the end of the podcast.
Do you fear death in what you've seen like examining
I think as a homicide detective, I have a certain
(01:04:53):
view on death from what you've seen. What's your take
on death because you've seen it in more ways than
most people in their life.
Speaker 2 (01:05:00):
Yeah, well, there are some ways I don't want to die,
but I'm not afraid of death as such. And one
of the reasons is early on in my time as
a coroner, it took me a while to go down
to the morgue and actually see how the forensic pathologists
(01:05:21):
and their teams examined the bodies of those who have died,
and it took away the fear of death itself from me.
People are very much at peace. They're not, you know,
whatever happened to them. They're no longer in pain. And
(01:05:41):
the other thing about working or getting to know the
people in the morgue was I got to know the
social workers who deal with the families, and I honestly
think they're saints. They were such good people and such
wise and behind people that I thought, you know, I
(01:06:04):
don't know if there's a life after death or not,
but at least in this place, those who are dead
are at peace, and those who are trying to help
their families are really good people. So it's not such
a bad way to go to end up in the morgue.
But yeah, I'm not afraid of my own death. I
(01:06:29):
really feel though, that we need to save lives. You know,
people we talked about what a good death is. I
would hope our society could ensure as many people as
possible have a good death, meaning a death, a peaceful death,
a death their families can accept reasonably peacefully. And I'd
(01:06:53):
say that about our common humanity. On Sunday there was
a march about Palestine. To me, many people down there,
Jews and Palestinians, Israelis and Palestinians. I think about those
people all the time.
Speaker 1 (01:07:10):
Yeah, it's hard not to think about when you see
the stuff like we're seeing going on overseas. It's horrible.
I heard I was at a university graduation and someone
doing the talk there. It was palliative care doctor, and
he just spoke and he'd had a lot of experience
(01:07:30):
in palliative care. And a question was asked of him,
what's the most frequent question that people ask you? What's
a good death? And he said, to live a good life?
And I thought that was a nice way of looking
at it, like it's how do you define a good death? Well,
maybe live a good life.
Speaker 2 (01:07:46):
Yeah, it's funny, isn't it. Three years ago I had
a sort of near death experience and while I was
waiting for the ambulance, thinking maybe this is it. That's
exactly what I didn't feel. I've lived a good life.
I felt i'd lived a lucky life, and I had
(01:08:07):
been very lucky. You two beautiful kids, lovely partner. I've
been lucky enough to do some work that's been really interesting,
meet really good people, work with them, and so I thought,
you know, if this is the end, I've been lucky.
Speaker 1 (01:08:25):
Were you thinking about whether you should have put in
recommendation that ambulances should respond.
Speaker 2 (01:08:33):
I was watching that. I was watching the clock.
Speaker 1 (01:08:37):
Damn it, I should have made that recommendation strong.
Speaker 2 (01:08:39):
I was actually thinking of that.
Speaker 1 (01:08:41):
Ye.
Speaker 2 (01:08:42):
Hello, how's this going well?
Speaker 1 (01:08:46):
I'm glad we haven't lost yet. Hugh, And thank you
so much for coming on the on the podcast, I've
really enjoyed having a chat with you. But I just
want to thank you for the work that you've done.
And at the start of the introduction, I talk about
it's there is that you're interested in? The passionate about
is something that I share and I think, whether it's
a homicide detective or acurr. And then we see the
(01:09:07):
pain that families go through where they lose loved ones
and they have someone like you with genuine empathy, care
and the smarts to get the strong message across. Congratulations
and thank you for your efforts.
Speaker 2 (01:09:19):
Oh, thank you, Garriot. It's been really interesting and a
real pleasure for me to have a chat with you.
It's been a long time. It has been very good
to see you again.
Speaker 1 (01:09:30):
Yep, good stuff. All the best for the future, and
keep pushing, pushing the reform.
Speaker 2 (01:09:35):
Certainly, I'm going home to send a letter to somebody today.
Speaker 1 (01:09:39):
No, it's good and important work that you're doing and
a lot of people would thank you for it.
Speaker 2 (01:09:44):
Thank you very much.
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