An Inquest taken on behalf of our Sovereign Lady the Queen at Port Lincoln in the State of South Australia, on the 7th and 8th days of December, 1999, and 19th day of January, 2000, before Anthony Ralph Newman, a Coroner for the said State, concerning the deaths of Marianne White and Samantha Jayne Pugh.

1. Background

1.1 On 6 December 1996 Marianne White was imprisoned for a period of four years with a minimum term of one year in the District Court at Wagga Wagga. She was sentenced in relation to a number of offences. They were two counts of break, enter and larceny and two counts of wilful damage by fire.

1.2 The sentence that she served was deemed to have commenced on 14 August 1996, and therefore the earliest date upon which she could be released pursuant to that sentence was 13 August 1997.

1.3 On 13 August 1997 she was in fact released from the Emu Plains Prison. Her parole was to expire on 13 August 2000.

1.4 The conditions of her release on parole included a condition that she may reside in South Australia, pending formal arrangements being finalised to transfer the Parole Order interstate in accordance with the provisions of the Parole Orders (Transfer) Act of 1983.

1.5 In fact, it was the intention of the New South Wales Parole Board that she move immediately upon her release to Ceduna in the State of South Australia, where she was to reside with her defacto husband, and the father of her daughter, Samantha Jayne Pugh, who had been born whilst the defendant was in custody.

1.6 Upon release she was advised to report to the office of the Department for Correctional Services at Ceduna on 20 August 1997 between the hours of 9.00a.m. and 4.00p.m.

1.7 Mr. Dew of Ceduna Correctional Services first saw her on 27 August. When spoken to, she said that she had not received a copy of the reporting or parole conditions, but that she and her defacto had arrived in Ceduna on 22 August 1997.

1.8 Mr. Dew continued to see the deceased on a reasonably regular basis. During September Mr. Dew became sufficiently concerned about her behaviour to seek assistance from Cheryl Wilson, a social worker and his immediate superior.

1.9 Cheryl Wilson saw Marianne White on 25 September 1997.

1.10 Initially, she was not overly concerned about Miss White’s mental condition, but that situation changed in the ensuing months.

1.11 By mid-November of 1997 it would seem that the relationship between Miss White and her defacto Mr. Pugh had, at least from her perspective, deteriorated, although Mr. Pugh was of the view that this was a result of her mental instability rather than any actual problem caused by him.

1.12 On 2 December 1997 Ms. Wilson provided a minute to the South Australian Parole Board providing information to assist them in coming to a decision as regards on-going supervision for Miss White at Ceduna.

1.13 At that point in time, it was decided to maintain her supervision at Ceduna.

1.14 Soon after that, Ms. Wilson became concerned regarding the mental state of Miss White following an episode where Miss White left Ceduna suddenly and moved to New South Wales for a short time.

1.15 On 13 January 1998 Ms. Wilson wrote to the South Australian Parole Board and was advised that she should make urgent contact with the Parole Board in New South Wales as, at that time, her parole had not been transferred to South Australia.

1.16 Ms. Wilson (then Mrs. Lawrence) prepared a letter dated 14 January 1998 to the Department of Corrective Services, New South Wales, in the following terms:-

Miss White has presented as an extremely difficult client to engage in most aspects of her responsibilities regarding supervision on parole. Over the last six weeks she has displayed an unstable and transient lifestyle and has breached her conditions on several occasions by

 

 

failing to report as and when required

leaving the State of South Australia without permission

leaving the State of New South Wales without permission

not attending medical/therapeutic appointments as directed.

Attached are minutes forwarded to the South Australian Parole Board, and casenotes providing an overview of Miss White’s recent behaviour.

 

In discussion with Mr. Kevin Hill, Secretary of the South Australian Parole Board, it is recommended that Miss White be directed to return to New South Wales by the New South Wales Parole Board and to not leave that State without permission. Ceduna is an isolated town of approximately 2,500 people and cannot provide Miss White with appropriate services necessary for her mental health condition. Miss White is also displaying no commitment to her responsibilities regarding her parole, which is obvious by her continual breaches of conditions".

 

1.17 Whilst Ms. Wilson faxed that to the New South Wales Parole Board, I have not been able to find a copy of that fax on the New South Wales Parole Board file. The original documents, however, are there date-stamped as having been received on 22 January 1998.

1.18 On 19 January 1998 Miss White advised Mr. Dew that she and her defacto Wayne Pugh were leaving the next morning to travel to Mount Wedge Station, approximately 30 kilometres from Elliston for a work-related holiday and would be there for approximately three weeks. She was advised to contact the Ceduna Correctional Services office on 27 January 1998.

1.19 On 20 January Mrs. Wilson sent a further fax to the New South Wales Parole Board in the following terms:-

"To whom it may concern

re Parolee Marianne White

 

Further to my fax dated 14/1/98 Miss White has travelled to Mount Wedge (approximately 30 kms west of Elliston) on Eyre Peninsula.

 

Miss White has also left messages last week on the home answering machine of the Ceduna Community Correctional officer’s phone. She never followed these up in further conversations.

 

As soon as is practicable, could this office be informed of any action which will be taken regarding Miss White".

 

1.20 That fax was received and is date-stamped 21 January 1998 on the New South Wales Parole Board file.

1.21 At about 7.00a.m. on 26 January 1998 Mr. Pugh and David Ladd left the units in which Mr. Pugh and Miss White were staying with Samantha for the day’s work.

1.22 He returned at approximately 3.00p.m. and was unable to locate either Miss White or Samantha. Whilst a search for them was begun that evening, this was to no avail.

1.23 The following day, 27 January 1998, an organised search was commenced and at about 4.30p.m. that day a member of the search team located the bodies of Miss White and Samantha Pugh.

1.24 Dr. Carmel Therese Shanahan of the Elliston Hospital attended at the scene where the bodies had been located and, after examination of both bodies, certified that, in relation to Miss White, life was extinct at 8.13p.m, and Samantha Pugh, that life was extinct at 8.15p.m. (see affidavit of Dr. Shanahan, Exhibit C.3a).

2. Cause of death

2.1 A post mortem examination was carried out on the body of the deceased Marianne White by Dr. J.D. Gilbert on 29 January 1998 at the Divett Place Mortuary, Adelaide. Dr. Gilbert’s report is Exhibit C.4a. He found that the cause of death was due to a .303 calibre gunshot wound to the central forehead. He noted that, due to the presence of severe putrefactive changes and heavy maggot activity, the macroscopic characteristics of the wound margins did not permit easy characterisation of the entry and exit wounds and estimation of the range of fire. Microscopic examination suggested that the forehead wound was the entry wound, but there was so little propellant residue identified that its pattern of distribution could not be assessed. There were no findings that indicated that the shot could not have been self-inflicted to the forehead at close range. No recent injuries which would indicate the involvement of another person in the death were identified.

2.2 I accept Dr. Gilbert’s opinion that the cause of death was a .303 calibre gunshot wound to the head.

2.3 A post mortem examination was carried out on the body of the deceased Samantha Jayne Pugh by Dr. R.W. Byard on 29 January 1998 at the Divett Place Mortuary, Adelaide.

2.4 Dr. Byard diagnosed the cause of death as gunshot wound to the head. This resulted in fractures of the underlying skull at both entry and exit points and extensive damage to the brain.

2.5 He noted that the presence of thermal changes and soot residue on the skin and soft tissue of the left side, with internal shelving of the skull, confirmed that this was a contact or near-contact entrance wound. He noted the presence of putrefactive change and entymological evidence indicated that the infant had been dead for several days and death was most likely to have occurred on or around 26 January 1998.

2.6 I accept Dr. Byard’s opinion that the cause of death was a gunshot wound to the head.

2.7 Dr. J.F. Wallman, an Associate Lecturer in Zoology at the University of Adelaide, examined samples of lavae taken from the skull cavity of both Marianne White and Samantha Pugh. In his report (Exhibit C.7a) he, having examined those lavae, estimated that the death of Marianne White occurred some time between 7.00a.m. and 3.00p.m. on 26 January, and that of Samantha Pugh between approximately 7.00a.m. on 26 January and 7.00a.m. on 27 January 1998.

2.8 I accept Dr. Wallman’s opinion as to the time of death of both persons.

3. Discussion

3.1 Subsequent to the location of the two bodies and the securing of the scene, an examination was carried out by Technical Services officer Kempster. His statement is Exhibit C.24a.

3.2 At about 7.30p.m. Mr. Kempster made a detailed examination of the scene. He noted that the body of the adult female (White) was on its back but it inclined towards the right side and the legs were extended. The left arm was back and around the head and over to the right side. The right arm was extended along the right side, with the hand over the rifle towards the trigger and under the carry strap. The muzzle of the rifle was located at the right shoulder and the right foot was still wedged between the carry strap and the stock of the rifle. The wound appeared to have been caused by the muzzle of the rifle touching the forehead between the eyes at the time of discharge.

3.3 He also examined the body of a small child (Pugh), which was secured in a pusher with straps across the waist and between the legs. Partially covering the child’s head was a blue adult-sized windcheater with holes consistent with bullet holes and what appeared to be portions of skull material adhering to the garment.

 

3.4 The investigation conducted by the police into the two deaths indicated that Marianne White shot her daughter Samantha Pugh with a .303 rifle and then shot herself with the same rifle. There is no evidence to suggest that any other person was involved in either death.

3.5 In this particular case the defendant Marianne White was released on parole from the New South Wales gaol system with the condition that she report directly to a community corrections officer in South Australia. She was not at any time referred to a community corrections officer in New South Wales.

3.6 The provisions of Section 8 of the Parole Orders (Transfer) Act are as follows:-

(1) At the request in writing of the designated authority for another State or a Territory of the Commonwealth, the Minister may, by instrument in writing, direct the Registrar to register under this Act a parole order that was enforced at the time of the request under a law of that State or Territory.

 

(2) The Minister shall not direct the registration under this Act of a parole order enforced under a law of another State or Territory of the Commonwealth unless -

 

(a) he is satisfied on consideration of relevant information and documents forwarded to him by the designated authority from that other State or Territory, that, having regard to the interests of the parolee, it is desirable that the parole order be so registered; and

 

(b) either

(i) the parolee has given his consent to, or requested, the registration of the parole order under this State;

or

(ii) the parolee is residing within this State.

 

3.7 Once registered in South Australia under this Act, pursuant to Section 10 of the Parole Orders (Transfer) Act, the laws of South Australia apply to the parole order of the New South Wales Court, as if the sentence of imprisonment to which the parolee was subject was imposed by a court in this State, and as if the parolee had been released on parole pursuant to an order made under the laws of South Australia.

3.8 In view of the costs of extradition proceedings pursuant to the Service and Execution of Process Act (Commonwealth), it is much more convenient for a parolee to be dealt with by the Parole Board in the State in which he or she is residing.

3.9 Neither Cheryl Wilson of the South Australian Correctional Services Department or James Jaku of the New South Wales Probation and Parole Service had had previous experience dealing with a parolee released to travel immediately interstate. As a result, it would seem that inadequate information was provided to the supervising parole officer in South Australia as to lines of contact.

3.10 It also seemed that the parole officers in South Australia (Mr. Dew and Ms. Wilson) did not attend to the registration of the parole order in South Australia as quickly as they perhaps should. Particularly given that the parolee had been specifically paroled with a condition that she reside in South Australia, it would seem that the parole in this case should have been registered almost immediately upon her transfer to South Australia, which would then have overcome the problem with lines of communication.

3.11 It seems to me that it is appropriate, given what has happened in this matter, to recommend, pursuant to Section 25(2) of the Coroners Act, that the Department for Correctional Services and corresponding bodies in each State or Territory which has passed a "corresponding law", as defined in the Parole Orders (Transfer) Act of 1983, should review their procedures in relation to interstate transfer of parolees. In particular it seems that, where a parolee is specifically directed to move interstate, urgent attention should be given to the registration of those parole orders. Further information should also be provided when a parolee is transferred interstate, advising the parole officer in the receiving State of the lines of contact, as it would seem that the systems from State to State are not uniform in this regard.

3.12 It is also of concern in this matter that the criminal history, which contains a number of warnings in relation to the possibility of the deceased Marianne White harming herself, was not made available to the parole service either in New South Wales or South Australia. The Department for Correctional Services in this State and the corresponding bodies interstate should review their procedures to ensure that all information of this nature is available.

3.13 A further, and more immediate matter of concern, is the fact that the deceased Marianne White was left alone with a loaded rifle in her immediate vicinity. This is in clear breach of the Firearms Act and has, in this case, led to two deaths. Mr. Pugh and other members of the community should be reminded of the dangers of leaving loaded firearms particularly in the near vicinity of persons who are known to be mentally unstable.

4. Conclusion

4.1 The evidence before me suggests that at some time between 7.00a.m. and 3.00p.m. on 26 January 1998 Marianne White shot her daughter Samantha Jayne Pugh and then shot herself.

5. Recommendations

5.1 The Department for Correctional Services and corresponding bodies in each State or Territory which have passed a "corresponding law", as defined in the Parole Order (Transfer) Act, should review their procedures in relation to the interstate transfer of parolees.

5.2 The Department for Correctional Services and corresponding bodies interstate should review their procedures to ensure that all information which may assist in the management of parolees, particularly those with a history of self-harm, be made available to Community Corrections officers.

5.3 The public should be reminded of the danger of leaving firearms, particularly loaded firearms, in an unsecured state.

 

 

 

 

 

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