CORONERS ACT, 2003
|
SOUTH |
|
AUSTRALIA |
FINDING OF INQUEST
An Inquest taken on
behalf of our Sovereign Lady the Queen at Adelaide
in the State of South Australia, on the 10th
day of September 2008, the 13th, 14th, 17th
and 20th days of October 2008 and the 3rd and 13th
days of November 2008,
by the Coroner’s Court of the said State, constituted of Mark
Frederick Johns,
State
Coroner,
into the death of Edward
James Wilson.
The said Court finds that Edward
James Wilson
aged 29
years,
late of South
Australia
died at the
Royal Adelaide Hospital, North Terrace, Adelaide,
South Australia on the 14th day of November
2005
as a result of air
embolus complicating gunshot wound to chest.
The said Court finds that the circumstances of his
death
were as follows:
1.
Introduction
and cause of death
1.1.
Mr Wilson was involved in an
exchange of gunfire with two police officers on Sunday morning, 13 November
2005. As a result of this
confrontation, he sustained two gunshot wounds. Neither of the wounds resulted in severe blood loss and Mr
Wilson was medically stabilised and transferred to the Royal Adelaide Hospital
shortly after the shooting. However,
some hours later, in the evening of Sunday, 13 November 2005, he experienced a
sudden collapse and cardiac arrest. During
emergency surgery it was found that the left ventricle of his heart was not
functioning, although the right side of the heart was.
At autopsy, Professor Byard was unable to determine an anatomical cause
of death. However, by correlating
the clinico-pathological information Professor Byard expressed the opinion
that the most likely cause of death was ‘air embolus complicating gunshot
wounds to chest’[1]
and I so find.
2.
Background
2.1.
Mr Wilson was 29 years of age.
He was born Edwards James Kelly at the Royal Women’s Hospital in
Brisbane on 5 October 1976. His
parents separated when he was 6 months of age.
Subsequently, his mother married another man called Keith David Wilson
and formally changed Edward’s surname accordingly.
In 1985 the family moved to South Australia.
From the age of 14 years Edward Wilson started to become rebellious and
his mother had difficulty controlling him.
He was reported by the local police for various minor offences and in
1991 he moved to Adelaide alone. He
was a ward of the State in 1992 and 1993 and was at that time living in
Adelaide.
2.2.
Mr Wilson had an extensive
criminal history dating from 1992. He
spent a total of 5 years and 9 months in prison as a result of his offending.
That is a cumulative figure – there were three separate periods of
imprisonment of varying lengths.
2.3.
During the 1990s, Mr Wilson was
known to police as a prolific illegal user of motor vehicles and for numerous
break and enter offences involving clothing stores.
Mr Wilson was known to be a drug user.
He regularly used methamphetamines, cannabis and ecstasy.
He had also been arrested for possession of heroin and was known to
have been on the methadone program and the bupromorphine program in 2002.
2.4.
Mr Wilson was last released form
incarceration in April 2005. During
the ensuing months he was suspected by police of being involved in a series of
serious criminal trespass, illegal uses and thefts from motor vehicles.
He was also suspected to have been involved in the production of
amphetamines during this period.
3.
The events of Saturday, 12
November and early morning Sunday, 13 November 2005
3.1.
As a result of his drug
connections, Mr Wilson met Leah Synnerdahl.
Ms Synnerdahl is a drug user. On
Saturday, 12 November 2005 Mr Wilson drove Ms Synnerdahl to Mellor Court,
Gilberton so that Ms Synnerdahl could obtain some drugs from a resident of a
group of units at that address by the name of Alan Yale.
An incident occurred there, the exact nature of which is not clear, but
it probably involved the supply of drugs.
This incident was followed by another encounter at the same address at
about 7am the following morning, 13 November 2005.
3.2.
At that time, Ms Synnerdahl and
Mr Wilson attended Mellor Court, Gilberton.
They drove there in a black Nissan Silvia, a vehicle that had been
stolen from Stanley Street, North Adelaide in the evening of 10 November 2005[2].
There is no evidence to prove that Mr Wilson stole the vehicle.
However, given Mr Wilson’s extensive criminal history, particularly
in motor vehicle theft, and the circumstance that Mr Wilson was driving the
vehicle several days later, it is more probable than not that it had been
stolen by Mr Wilson that night. Alan
Yale approached Ms Synnerdahl in the vehicle.
Mr Wilson became aggressive and argued with Mr Yale.
He then got out of the vehicle and threatened Mr Yale with a sawn-off
rifle. Mr Wilson demanded that Mr
Yale take him to Mr Yale’s unit. After
some prevarication, Mr Yale led Mr Wilson to the unit but ran into his bedroom
and shut himself in there. Mr
Wilson tried to kick the door down and then discharged one shot from the
firearm through the bedroom door. No
person was injured as a result of this shot.
Mr Yale moved from the door and Mr Wilson was able to gain entry to the
bedroom. He stole Mr Yale’s car
keys, one hundred dollars in cash, two ecstasy tablets and a key ring. Mr Wilson then left the unit and accosted two other persons
outside, stealing a mobile phone from one of them. He left with Ms Synnerdahl in the stolen Nissan Silvia.
3.3.
At this point, Mr Yale rang the
triple zero emergency number and reported that there had been a shooting.
Police officers from Holden Hill CIB were despatched to Gilberton where
they commenced investigations. Those
officers were subsequently joined by Detective Senior Constable Robert Lengyel,
Senior Constable Craig Johnston and Detective Senior Constable Alex Grimaldi
of Holden Hill CIB. Those three
officers were present at 7 Kings Avenue, Burnside when Mr Wilson was shot and
wounded later that morning. All
three officers gave evidence at the Inquest.
3.4.
On arriving at the Gilberton
address, the three officers to whom I have just referred were briefed on the
situation by other members of Holden Hill CIB. They learnt that the officers in attendance had heard
different accounts from Mr Yale of what had occurred earlier that morning.
Detective Lengyel said that Mr Yale was clearly trying to avoid
implicating himself in drug dealing. Senior
Constable Johnston gave evidence that he thought that Mr Yale was not telling
the truth and was under the influence of cannabis.
Detective Grimaldi formed a similar view.
3.5.
Although all police at the scene
were dubious about Mr Yale’s credibility, there was no doubt that a firearm
had been used by a male person who had arrived in a black vehicle with a woman
and that person had left the scene. It
was clearly necessary for police to further investigate.
The evidence established, and I find, that Mr Yale offered to take
police to the address at which he believed the woman, who he identified to
police only by the name ‘Leah’ lived.
This offer was accepted and officers Lengyel, Johnston and Grimaldi
took Mr Yale in a police vehicle so that he could assist them in identifying
the address. It became apparent
within a fairly short time that Mr Yale was not at all certain of the correct
address. According to Detective
Lengyel, Mr Yale said that he had only been to Leah’s address twice before
and then only at night[3].
Senior Constable Johnston formed the view that Mr Yale was very
unreliable, and that he would probably just pick any address at random[4].
Senior Constable Johnston described Mr Yale as being very jumpy and
behaving as if he was affected by drugs.
Detective Grimaldi said that as they drove through certain backstreets
in Burnside, Mr Yale was ‘humming and harring’[5]
and picking out houses but changing his mind a lot. Detective Lengyel said that Mr Yale identified two houses in
Hill Street, Burnside which were possibilities although he was not confident.
After this he directed police to another street, Kings Avenue, Burnside
and identified a house at number 7. The
impression gained by Detective Grimaldi was that Mr Yale did not definitively
identify the address at 7 Kings Avenue, but that he was more confident of that
address than the two in Hill Street.
3.6.
As the group drove past these
various houses the officers kept an eye out for any sign of the black Nissan
Silvia. However, it was not
sighted near any of the houses. In
particular, it was not seen at the address at 7 Kings Avenue, Burnside nor in
the near vicinity. Mr Yale told
the officers that Leah had worked at the Feathers Hotel in the past but he did
not seem to think she was currently working there.
3.7.
The three officers returned with
Mr Yale to Holden Hill Police Station where he was required to give a
statement. Detective Lengyel
caused computer searches to be carried out in relation to any information that
might be held by South Australia Police about a woman called Leah at any of
the addresses that had been identified by Mr Yale.
The searches were carried out by Senior Constable Karran[6].
He conducted a number of checks on 7 Kings Avenue, Burnside and the
whole of that street to try to find a woman by the name of Leah who may have
lived at the address or in the street. He
found no person named Leah as a result of those checks.
He conducted checks on other police databases looking for any person
named Leah who may have links to the Burnside address.
He also conducted checks on the two other streets at Detective
Lengyel’s request, again searching for a person named Leah living on those
streets but without any result. From
all the checks conducted there was nothing to suggest that a Leah was living,
or had at any time been recorded as living at 7 Kings Avenue, Burnside.
4.
The events at 7 Kings Avenue,
Burnside
4.1.
At this point Detectives Lengyel
and Grimaldi and Senior Constable Johnston decided that they would physically
attend at the addresses nominated by Mr Yale.
They regarded this task as a general enquiry intended to exclude these
addresses from the investigation. Detective
Lengyel said that he did not believe that he would obtain any information
helpful to the investigation at any of the addresses that had been identified
by Mr Yale because of Detective Lengyel’s assessment of Mr Yale’s
credibility. The other two
officers had reached a similar view but it was common ground that it was
necessary to exclude the addresses as they had been nominated.
4.2.
As a result of this, the three
officers attended again at 7 Kings Avenue, Burnside because it was the last of
the addresses nominated by Mr Yale. They noted that the Nissan Silvia vehicle was not in the
driveway. The evidence of the
three officers establishes that Detective Grimaldi walked down the driveway
towards a carport at the rear of the property.
Detective Lengyel and Senior Constable Johnston walked down a diagonal
path from the driveway leading to the front door of the premises.
7 Kings Avenue, Burnside is an ordinary suburban house in an older
style. It has a driveway leading
down the right hand side of the allotment as one looks at it from the street.
Immediately to the left of the driveway is the house which can be
approached by the diagonal path I have mentioned.
That path leads through an area planted in shrubs and trees.
These shrubs and trees give an impression of being somewhat overgrown.
I have seen photographs of the premises which were admitted as Exhibit
C40c. The house is single fronted with a bedroom to the right of
the front door and a central passageway leading directly from the front door.
To the left of this is another front room.
The doorway and the front room to the left of it are set back
approximately 2 metres from the alignment of the front bedroom to the right of
the doorway. The area immediately
outside the doorway forms a porch. The
front bedroom has a window in the wall facing the street.
When the officers approached the house, the blinds to that bedroom were
drawn.
4.3.
Detective Lengyel and Senior
Constable Johnston approached the front door and knocked on it.
It was opened by a man who was later identified as Ms Synnerdahl’s
brother. Detective Lengyel
identified himself and asked if there was a person called Leah at the house.
The man did not fit the description of the male offender and
accordingly Detective Lengyel had no reason to be concerned at that point.
Ms Synnerdahl’s brother responded to this enquiry affirmatively.
He turned and approached a doorway immediately to the right, just
inside the front door. This doorway led to the front bedroom, which I have already
described. He knocked on the
bedroom door saying words to the effect of ‘Leah, it’s the police’.
A woman who I find was Ms Synnerdahl came out of the bedroom and closed
the door behind her. Detective Lengyel stepped further into the house and asked
her if she knew about the shooting which had taken place at Gilberton that
morning.
4.4.
He was still uncertain if this
person was the Leah he was looking for. He had a level of concern but he noted that the woman looked
dishevelled and was rubbing her eyes. She
denied any knowledge of the incident at Gilberton and said she had been asleep
all morning. She then became
abusive and aggressive.
4.5.
In the meantime, Detective
Grimaldi had walked down the driveway to the right of the house and approached
the carport which is attached to the house at the rear.
He found that there was a curtain of green shade cloth hanging from the
facia at the front of the carport which had not been clearly apparent when he
had first sighted the carport from the top of the driveway.
When he reached the shade cloth curtain he pulled it aside and entered
the area under the carport. He
saw a black Nissan Silvia which matched the description from the Gilberton
incident. He went to the front
door of the house to inform Detective Lengyel and Senior Constable Johnston
that the vehicle was there. When he reached the front door Detective Lengyel and Senior
Constable Johnston were already inside the house with Detective Lengyel
further inside and Senior Constable Johnston just behind him. Detective Grimaldi saw that Detective Lengyel was talking to
a woman. He went to the doorway
and quietly told Senior Constable Johnston that he had found the vehicle.
Senior Constable Johnston made a gesture which acknowledged that he had
understood this communication. Detective
Grimaldi then decided to return to the vehicle to see if he could find the gun
inside it. He did not know at
that stage who the female was. He
went back to the vehicle and found nothing from an external inspection.
4.6.
He returned to the front of the
house and as he went past the window of the front bedroom he could hear a
noise coming from the window. He
saw that a blind had been partly raised on one of the panes furthest from the
front door. He was not aware of
what Detective Lengyel and Senior Constable Johnston were doing at that time.
He looked inside the window and saw a male standing at the window
trying to open it. In a loud
voice he said ‘we are the police, come out with your hands on your head’.
His intention in speaking loudly was to make himself heard to the male,
but also to make himself heard by his colleagues.
The male stepped away from the window and Detective Grimaldi saw a bed
behind him with a sawn-off rifle lying on it.
He then yelled out words to the effect ‘there’s a gun’ to let
Detective Lengyel and Senior Constable Johnston know what he had seen.
He then moved to the front door.
4.7.
In the meantime, Detective
Lengyel had asked to see inside the bedroom, the door of which Leah had
closed. She did not cooperate and
he pushed her aside to see who was inside the bedroom.
On opening the door he saw the male who had also been seen by Detective
Grimaldi from outside. This male was Mr Wilson.
Detective Lengyel said that Mr Wilson was walking towards him and was
holding a sawn-off rifle at waist level which was pointed towards Detective
Lengyel. Detective Lengyel said
that he made eye contact with Mr Wilson, dropped the papers he was holding and
drew his service revolver. He
yelled words to the effect ‘police, put your gun down, put your gun down’
and moved backwards out of the bedroom, through the door and towards the front
door. Mr Wilson followed him and
as he came out of the bedroom doorway he turned to the left and turned the gun
to the left at the same time. Detective
Lengyel said he then heard a gunshot. He
retreated further and went down on his haunches trying to avoid being shot.
He was on one knee immediately to the right hand side of the front door
of the house and just inside. The
door hinges from its right hand side and accordingly, the door being partially
open, he was in a confined space bordered by the door and the wall of the
front bedroom. Detective Lengyel
said he had continuous eye contact with Mr Wilson and the latter continued
moving towards him. At this point
Detective Lengyel shot Mr Wilson through the chest.
Detective Lengyel said that he thought that Mr Wilson had shot at him
and was surprised that he had missed. He
thought that Mr Wilson was going to kill him.
He said that he could not withdraw any further and was trapped in the
corner. Detective Lengyel said
that as he had opened the bedroom door he heard Detective Grimaldi yelling out
words to the effect ‘he’s inside, he’s got a gun’ but by that stage
Detective Lengyel was actually in the bedroom and Mr Wilson was moving towards
him. Detective Lengyel said that
there was less than a minute between their arrival at the front door and the
discharge of his service revolver.
4.8.
Senior Constable Johnston in the
meantime had stepped outside the house after being informed by Detective
Grimaldi that the vehicle was present at the house.
He had attempted to impart that information to Detective Lengyel
quietly but it is not clear that Detective Lengyel heard him.
After seeing Detective Grimaldi move back down the driveway Senior
Constable Johnston’s attention was drawn to some movement at the bedroom
window. At this point Detective
Grimaldi returned around the side of the house.
Senior Constable Johnston returned to the front door with the intention
of telling Detective Lengyel that someone was trying to get out of the bedroom
window. By this time, Detective
Lengyel had his firearm drawn and was backing out of the bedroom and Senior
Constable Johnston had heard Detective Grimaldi shout out about the gun.
As Detective Lengyel backed out, Senior Constable Johnston heard what
he described as a ‘loud pop’. He
said that he did not fully comprehend what the popping sound was but he
instinctively realised that it was a gun firing.
He said that it sounded different to a SAPOL service revolver.
He said it sounded like a low calibre weapon.
4.9.
Detective Lengyel said that
after he fired his gun at Mr Wilson’s chest, the latter continued to move
towards the front door, pushing it shut.
He turned, dropped the gun and moved up the hallway before collapsing
on the floor. At this point
Detective Lengyel heard banging on the front door from Detective Grimaldi and
Senior Constable Johnston trying to get in.
4.10.
After seeing Mr Wilson from
outside the bedroom window Detective Grimaldi said that he moved to the front
door to back up Detective Lengyel and Senior Constable Johnston.
He recalled passing Senior Constable Johnston on his way back to the
front door. As he came around the
corner of the bedroom wall he could see inside the front door and could see
Detective Lengyel still inside the house crouching against the wall in the
hallway. In the meantime he had
heard what he thought was a shotgun being discharged.
He described the sound as being unlike the sound of a SAPOL issue
revolver. His vision of Detective
Lengyel was then obscured by the male he had seen through the bedroom window
– Mr Wilson. Mr Wilson was
standing in the front door and appeared to Detective Grimaldi to be holding it
with his left hand. Mr Wilson had
the shotgun in his right hand at waist height and it was levelled in Detective
Grimaldi’s direction. Detective
Grimaldi thought that Mr Wilson was going to shoot him and discharged his
service revolver. Almost
immediately the front door shut and the bullet fired by Detective Grimaldi
went through the frosted glass panel in the front door. Detective Grimaldi then saw through the frosted glass a male
person’s silhouette fall to the ground.
He and Senior Constable Johnston immediately ran to the front door to
get in.
4.11.
Detective Lengyel opened the
front door to allow his colleagues inside the house.
He was not injured from the bullet discharged by the sawn-off rifle.
4.12.
During this action Ms Synnerdahl
had moved to a bathroom to the right of the house and further down the
hallway. Her brother had moved to
a room at the back of the house to which the hallway leads.
4.13.
Senior Constable Johnston called
for an ambulance using the police radio and the officers began to administer
first aid to Mr Wilson, who was conscious at the time.
Mr Wilson was resisting the officers' attempts however they managed to
place him in the coma position. Mr
Wilson experienced difficulty breathing in this position and the officers
moved him into a sitting position for fear that he may have lung damage.
4.14.
The bullet discharged by
Detective Grimaldi’s gun was not seen by him to hit Mr Wilson because the
door was closed immediately upon the weapon being discharged.
A scene reconstruction was carried out after the shooting by crime
scene police. It demonstrated
that there was a whole in the glass panel of the front door caused by the shot
fired by Detective Grimaldi. The
projectile was found to have hit a sliding doorway at the end of the hallway
and was lying at the foot of that doorway on the carpet.
Mr Wilson was found to have had four gunshot wounds to his upper body.
Three of those wounds were on his chest and the fourth was on the front
part of his upper arm, immediately below shoulder level.
Subsequent investigations by Professor Byard revealed that three of the
wounds were caused by a single projectile.
The wound to the upper right arm was a glancing, gouging, superficial
wound. It was caused by a
projectile which gouged across the arm, went into the right side of the chest
and emerged at a point in line approximately with the midline of the chest.
5.
Mr Wilson’s treatment at
the Royal Adelaide Hospital
5.1.
Immediately after the shooting
Mr Wilson was semi-conscious. Intensive
Care Paramedic Robert Snell described him as being in an altered state of
consciousness. He was not fully
alert and oriented. He was having
difficulty breathing and oxygen was applied by the paramedics.
Their main objective was to remove him from the scene as soon as
possible and deliver him to the Royal Adelaide Hospital.
The hospital was advised to be ready for a patient with a penetrating
wound. Mr Snell said that the period from his arrival to the
ambulance leaving for the Royal Adelaide Hospital with Mr Wilson was
approximately 5 minutes.
5.2.
Dr Peter Bautz is a consultant
and general trauma surgeon with extensive experience in gunshot wounds, having
practised in South Africa before coming to Australia.
He said that he was present when Mr Wilson arrived at the Royal
Adelaide Hospital. Mr Wilson was
oriented and had a very high heart rate at 110 beats per minute.
He was breathing very fast at 40 respirations per minute.
The initial indications were that he had a lung injury or perhaps a
heart or vascular injury. Soon
after his arrival, his respiratory status deteriorated and his oxygen
saturations dropped as low as 82% despite the fact that he was breathing 100%
oxygen[7].
It was clear that Mr Wilson had a significant problem with exchanging
gas across the lung membrane[8].
As a result, he was intubated and placed on mechanical ventilation.
After this his oxygen saturations stabilised at 98% to 100%.
Chest drains were inserted and as Mr Wilson was in a stable condition
and had no immediate need for emergency surgery he was transferred to the
Intensive Care Unit (ICU)[9].
5.3.
From the imaging that had been
performed to that point it was clear that there was no projectile in Mr
Wilson’s lung nor in his abdomen. One
of the bullets had travelled from front to back through his chest, missing his
lungs and lodging in his right shoulder. There was no sign of the other projectile.
It was this latter projectile that was subsequently found in the house
as I have described above. There
was no damage to any of the major blood vessels and the appropriate course was
to allow him to stabilise at that point.
The medical expectation was that he would survive.
5.4.
Such was the position at around
lunchtime on that Sunday. However,
Mr Wilson suffered a cardiac collapse shortly before 7pm the same day.
Dr Hockley, an Intensivist and Senior Registrar in the ICU in 2005, was
called at that time. Mr Wilson
was bradycardic, his heart rate having dropped to 40 beats per minute.
Atropine was administered with fluid boluses and adrenaline.
This was followed by a complete cardiovascular collapse.
Dr Hockley contacted Dr Bautz and requested that he attend as soon as
possible. Dr Bautz arrived
shortly afterwards. It was Dr
Hockley’s opinion that the most likely explanation for the collapse was a
pericardial tamponade. Dr Bautz
agreed with this hypothesis and a thoracotomy was performed to expose the
heart and exclude a pericardial tamponade.
The heart and the lung were exposed and it was clear that there was no
pericardial tamponade. The
pericardium was opened and the heart was exposed.
Only then did it become apparent that the left ventricle of the heart
was not working properly. The
doctors then performed internal cardiac massage and were able to re-establish
cardiac output. Internal cardiac massage was performed for approximately one
hour during which the cardiothoracic theatre was prepared in order that Mr
Wilson could be placed on cardiopulmonary bypass.
This occurred and when Mr Wilson had been placed on effective bypass
the internal cardiac massage was stopped.
During that procedure the middle lobe of the right lung was removed, it
having been found to be severely contused.
In the result, the surgeons were unable to withdraw the cardiopulmonary
bypass equipment successfully and after several attempts to do this Mr Wilson
died.
5.5.
Dr Hockley said that when he
first exposed Mr Wilson’s heart for internal cardiac massage he saw that the
right side of the heart was contracting vigorously but the left side of the
heart was not at all. It was
making some minor sluggish movements and was quite dilated[10].
Dr Hockley said that when he opened the heart he saw air in the
coronary arteries[11].
He said that his clinical impression at the time was that Mr Wilson had
an air embolus or air passing from the pulmonary vessels into the left side of
the heart.
5.6.
It was the general consensus of
the medical witnesses that the very severe injuries to Mr Wilson’s lung
caused a defect in the air spaces of the lung which allowed air to escape
under the pressure of positive ventilation into his pulmonary arteries.
Only a very small amount of air is required to produce a fatal outcome.
Professor Byard was of the opinion that it would not have been possible
for the clinicians at the hospital to detect the air embolus, nor to prevent
it. Once the embolus occurred
events unfolded very quickly, with heart failure soon after.
5.7.
The extensive lung injuries were
not caused by a direct penetrating wound from a projectile.
Rather, they were the result of a blast effect of a projectile passing
in close proximity to the lung. In
fact, the projectile in question had passed very close to the lung and the
kinetic energy from the projectile was transferred to the soft tissue
surrounding the path of the bullet. Much
of this was lung tissue with the result that there was extensive contusion of
the excised portion of the right lung. This
was found at autopsy to have a consistency entirely unlike that normally found
in a lung. Rather than being
pliable and spongy, it had the consistency of a solid organ such as a liver. Professor Byard’s conclusion was that the pulmonary embolus
was a rare and unfortunate outcome which could not have been expected[12].
As Dr Bautz observed, a pulmonary embolus in this situation is very
uncommon and it occurs in only 4% or 5% of cases[13].
6.
Conclusions
6.1.
On a consideration of the events
that occurred at the Royal Adelaide Hospital and the evidence, particularly of
Professor Byard, it is my opinion that Mr Wilson’s collapse could not have
been anticipated by the clinicians. Indeed, he would have been expected to survive following the
assessment and initial stabilisation. There
was no deficiency in his treatment. Indeed, all concerned did all they reasonably could and the
resuscitation after his sudden collapse involved quite heroic efforts to
sustain his life.
6.2.
I conclude in relation to the
actions of the police officers that Senior Constable Johnston and Detectives
Lengyel and Grimaldi acted appropriately and fulfilled their duties exactly as
they should have done. In the
course of the investigation into this matter, which was conscientiously and
thoroughly carried out by Detective Chief Inspector Paul Greathead, the
possibility that the officers should have treated the visit to 7 Kings Avenue,
Burnside as a high risk tasking, and obtained permission from other senior
officers, and possibly the State Duty Officer, was raised.
In my view a balance has to be drawn between the exercise by officers
of appropriate investigative initiative and the exercise of caution in
appropriate cases. In this case
the officers reasonably believed that they were unlikely to be confronted with
a situation of danger at any of the houses that had been so tentatively and
uncertainly pointed out by Mr Yale. The officers had formed a view that none of the houses would
yield a result and their reason for attending was to exclude them from the
investigation given that they had been marked out by Mr Yale.
It would not have been appropriate to ignore the premises altogether in
the investigation. Nor would it
have seemed appropriate to place the premises under surveillance in the hope
that they might be excluded from contention in that way.
In my view, the officers acted appropriately, reasonably and
diligently. Unfortunately, they
were placed in a situation of mortal danger with a very distressing outcome.
Detectives Lengyel and Grimaldi were placed in the invidious position
of having to discharge their firearms in what they quite reasonably regarded
as a situation of self-defence. No
doubt this episode has been very distressing for them.
It was clear that the experience of giving evidence in this Court was
not an easy one for either of the officers.
They were more than equal to the task however, and each of them gave
their evidence openly and with obvious sincerity.
I hope they will be able to put this incident behind them and continue
with their policing careers in the knowledge that they acted appropriately in
the execution of their duties. It
is a grave thing to discharge a weapon at another human being and might lead
to anguish and rumination. In
this case that should not be so. Detectives
Lengyel and Grimaldi are entitled to put this incident behind them and get on
with their careers.
6.3.
Mr Wilson had an unfortunate
upbringing. Some reference to
this is made in sentencing remarks of two Judges of the District Court in
sentencing him in 1996 and 2001. Interestingly,
in the latter incident there is reference to an impetuous assault and robbery
by Mr Wilson of a person who he asserted owed him money in connection with a
drug transaction. This has a
familiar ring considering the circumstances in which Mr Wilson came to the
attention of police on 12 November 2005.
Mr Wilson had little or no respect for authority.
His attitude to the police is evident from tattoos present on the back
of the fingers of each hand: the letters ‘COPS’ were present on the back
of the fingers of the right hand and the letters ‘SUCK’ were present on
the back of the fingers of the left hand[14].
Unfortunately, it appears that Mr Wilson was likely to be involved in
an incident in which either he or someone else would be severely injured as
his criminal behaviour intensified in the last weeks of his life.
The discharging of the firearm in Gilberton through a closed door which
was obviously being blocked by Mr Yale on the other side, could well have
resulted in Mr Yale’s death or serious injury.
Mr Wilson showed a reckless disregard for Mr Yale’s life.
The police officers who attended 7 Kings Avenue, Burnside were aware of
this and had every reason to fear for their lives when he brandished the
sawn-off rifle in their direction and discharged it.
7.
Recommendations
7.1.
It will be apparent from all I
have said that there is no need for me to make any recommendation in relation
to this matter.
Key
Words: Death
in Custody; Gunshot Wound; Police
In
witness whereof the said Coroner has hereunto set and subscribed his
hand and
Seal
the 13th
day of November,
2008.
State
Coroner
Inquest Number 29/2008 (2905/2005)
[1] Exhibit C104
[2] See Exhibit C17a
[3] Transcript, page 51
[4] Transcript, page 100
[5] Transcript, page 150
[6] Exhibit C27a
[7] Transcript, page 325
[8] Transcript, page 325
[9] Transcript, page 293
[10] Transcript, page 335
[11] Transcript, page 335
[12] Transcript, page 246
[13] Transcript, page 301
[14] See autopsy report of Professor Byard, Exhibit C104