Inquest into the death of Rebecka Shermaine Hans

CITATION: Inquest into the death of Rebecka Shermaine Hans [2008] NTMC 066

TITLE OF COURT: Coroner’s Court

JURISDICTION: Coronial

FILE NO(s): D0180/2007

DELIVERED ON: 10 October 2008

DELIVERED AT: Darwin

HEARING DATE(s): 8 October 2008

FINDING OF: Mr Greg Cavanagh SM

CATCHWORDS:
Death in Custody, suicidal deceased, police efforts to assist, suicide

REPRESENTATION:

Counsel:
Assisting: Jodi Truman

Judgment category classification: A
Judgement ID number: [2008] NTMC 066
Number of paragraphs: 83
Number of pages: 22

IN THE CORONERS COURT
AT DARWIN IN THE NORTHERN
TERRITORY OF AUSTRALIA

No. D0180/2007
In the matter of an Inquest into the death of
REBECKA SHERMAINE HANS
ON 24 OCTOBER 2007
AT ROYAL DARWIN HOSPITAL

FINDINGS

(10 October 2008)

Mr Greg Cavanagh SM:
INTRODUCTION
1. Rebecka Shermaine Hans was a Caucasian female born on 21 January 1989 in Townsville, Queensland. The body of Ms Hans was found by police on the veranda of her residence at Lot 1255 Leonino Road, Darwin River in the Northern Territory at approximately 2.19pm on Wednesday 24 October 2007.
2. At the time of her death, police were in the process of endeavouring to take Ms Hans into their control in order to assess her mental stability. This was as a result of Ms Hans telephoning the police in the early hours of 24 October 2007 and advising them that she intended to commit suicide and requesting that they attend to look after her dogs.
3. As a result, the death of Ms Hans was reportable to me, as the Coroner, pursuant to section 12 of the Coroners Act (“the Act”). Ms Hans was determined to be a person held in custody pursuant to the definition contained in section 12 of the Act including:
“A person in the process of being taken into the custody or control of a member of the Northern Territory Police Force”
As a result, pursuant to section 15(1) of the Act, this inquest is mandatory.
4. Section 26 of the Act provides:
“(1) Where a Coroner holds an inquest into the death of a person held in custody or caused or contributed to by injuries sustained while being held in custody, the Coroner –
(a) Shall investigate and report on the care, supervision and treatment of the person while being held in custody or caused or contributed to by injuries sustained while being held in custody; and
(b) May investigate and report on the matter connected with public health or safety or the administration of justice that is relevant to the death.
(2) A Coroner who holds an inquest into the death of a person held in custody or caused or contributed to by injuries sustained while being held in custody shall make such recommendations with respect to the prevention of future deaths in similar circumstances as the Coroner considers to be relevant”
5. Pursuant to section 34 of the Act I am also required to find if possible:
“(1) A Coroner investigating:
(a) A death shall, if possible, find –
(i) The identity of the deceased person;
(ii) The time and place of death;
(iii) The cause of death;
(iv) The particulars needed to registered the death under the Births, Deaths and Marriages Registration Act;
(v) Any relevant circumstances concerning the death”
6. Section 34(2) of the Act operates to extend my function as follows:
“A Coroner may comment on a matter, including public health or safety or the administration of justice, connected with the death or disaster being investigated”
7. This inquest was held on 8 October 2008 and I provide these extempore reasons for my decision. Ms Jodi Truman of Counsel appeared as Counsel assisting me in this inquest. There were no other formal appearances, although it is noted Ms Korina Mansfield, the mother of the deceased, and her partner, Mr Michael Houston were in attendance at the Inquest.
8. Four witnesses were called to give evidence at the inquest. Those persons were:
a. Ms Korina Mansfield, mother of the deceased;
b. Detective Senior Sergeant Scott Pollock, the Officer in Charge of the Coronial investigation;
c. Mr Luke Smith, who was the last person to see the deceased alive; and
d. Superintendent Robert Farmer who was the Operation Commander of the incident prior to the death of Ms Hans and in the overall charge of the matter on 24 October 2007, following the deceased’s contact with the police.
9. A brief of evidence containing 30 civilian witness statements and 37 police statements, together with numerous other reports, photographs and police documentation was tendered at the inquest (Exhibit 2). Public confidence in Coronial investigations demands that when police (who act on behalf of the Coroner) investigate deaths that involve police that they do so to the highest standard. Detective Senior Sergeant Scott Pollock has done so. He carried out his investigation to a high standard and I thank him for his efforts.
Formal Findings
10. On the basis of the tendered material and oral evidence at this inquest I am able to make the following formal findings in relation to the death of Ms Rebecka Hans, as required by the Act:
(i) The identity of the deceased was Rebecka Shermaine Hans who was born on 21 January 1989 in Townsville, Queensland.
(ii) The time and place of death was at approximately 2.19pm on 24 October 2007 at Royal Darwin Hospital.
(iii) The cause of death was a gunshot wound to the head.
(iv) Particulars required to register the death:
a. The deceased was female.
b. The deceased’s name was Rebecka Shermaine Hans.
c. The deceased was of Caucasian descent.
d. The cause of death was reported to the Coroner.
e. The cause of death was confirmed by post mortem examination carried out by Dr Terry Sinton.
f. The deceased’s mother was Korina Gay Hans. The deceased’s father was Karl Hans.
g. The deceased lived at Lot 1255 Leonino Road, Darwin River with her de facto partner, Luke Randolf Furnell.
h. The deceased was employed as a casual labourer.
Circumstances surrounding the death
11. Rebecka Shermaine Hans was the only child to Karl and Korina Hans. The family moved to Perth, Western Australia when the deceased was still a child. The deceased endured a turbulent family relationship up until the age of 10 years when her father separated from the family.
12. According to a number of civilian statements tendered in evidence before me, it appears that Ms Hans suffered a number of personal traumas as a child, which significantly impacted on her view of herself and also on her relationship with her mother. It is not necessary for the purpose of this inquest to detail those matters in these findings however I do note the content of the statements that relate to this issue.
13. It appears that as a result of those things that Ms Hans struggled to consider herself a person “worthy” of personal compliments and struggled with her past from time to time.
14. It appears from some of the civilian statements tendered in evidence that the relationship between the deceased and her mother had had its difficulties but the deceased and her mother had reconciled and it appears that they kept in regular contact and expressed a great deal of love towards one another.
15. According to the statement provided by the deceased’s mother to the police, it appears that the deceased had previously threatened suicide on one prior occasion in her short life, but that she had eventually overcome those difficulties with the assistance of her mother. I note however that the deceased’s mother reports that she had always desired the deceased to undertake some more formal treatment, such as counselling, following that incident, but this never occurred.
16. At the age of 17 the deceased met Mr Luke Furnell, who was at that stage aged 25 years. The two commenced a de facto relationship, which endured up until the time of her death. It appears that for all intents and purposes this was a close and loving relationship for the deceased and one that she held in high regard.
17. In approximately July 2007 the deceased and Mr Furnell moved to Darwin. Mr Furnell purchased a property at Lot 1255 Leonino Road at Darwin River. Mr Furnell was employed as a labourer on an off shore oilrig. Mr Furnell’s work shifts occurred on a 3-week on/3 week off period. On occasion Mr Furnell stayed for longer periods.
18. As a result Mr Furnell was regularly away from the home and from the deceased. It appears from some of the civilian statements, and a copy of 2 diary entries that was tendered in evidence before me (exhibit 1) that the deceased reported feeling loneliness with the absence of Mr Furnell, however it does not appear that she admitted this to Mr Furnell directly.
19. It appears that in or about early October 2007 the deceased began struggling to cope with various issues. This resulted in some behaviour, which the deceased had not undertaken for quite some time, particularly involving alcohol usage. It appears from some of the civilian statements that the deceased also undertook some other risk taking behaviour during this time, which was not within her usual habits.
20. I also find that during this period the deceased developed a friendship with a Mr Luke Smith. It is clear from a number of civilian statutory declarations tendered in evidence before me that Mr Smith and the deceased spent regular time with one another and would drink regularly together at the Humpty Doo Pub and had also undertaken pig shooting with one another.
21. It appears however that perhaps the relationship between the deceased and Mr Smith may not have always been good with some of the statutory declarations given by civilians revealing that the deceased sometimes expressed to persons a very happy and beneficial friendship with Mr Smith and on other occasions indicating that she no longer wished to spend any time with him whatsoever.
22. Mr Smith gave evidence before me and indicated that at all times he considered Ms Hans a good “mate” and a friend. He didn’t indicate there had been any problems as far as he was aware in their relationship. I pause to note that Mr Smith was at the time also involved in a long term relationship and although both the deceased and Mr Smith were partnered, he never actually met Ms Hans’ partner and his partner had only met Ms Hans on one occasion.
23. As stated earlier in these reasons, I find that Mr Smith was the last person to see the deceased alive. I find that on 23 October 2007, ie. the day prior to her death, with Mr Furnell still away, the deceased rang Mr Smith looking for a battery charger. I find that Mr Smith stated he could get her a charger and she offered to collect him from his place of employment and return him to his residence in Humpty Doo.
24. I find that at this time Mr Smith accepted the deceased’s offer and the deceased collected Mr Smith from his work at about 5.30pm. I note that a number of other civilians, who were work mates of Mr Smith, saw the deceased collect Mr Smith at that time. I find that the deceased and Mr Smith then left Mr Smith’s place of employment and began travelling to his residence at Humpty Doo. I find that on the way they attended at the Humpty Doo Bottle Shop and purchased some alcohol.
25. Part of the coronial investigation brief tendered before me expressed concern as to the precise events that occurred after the deceased and Mr Smith left his place of employment. It is clear that Mr Smith, even by his own admission, did not tell the police the truth when he first had contact with them and was not frank nor forthcoming.
26. Understandably concerns have therefore arisen in the mind of police about the bona fides of Mr Smith, significantly as a result of Mr Smith failing to tell them the truth when he was given the opportunity to do so following his first contact with them in the early hours of 24 October 2007.
27. As a result Counsel assisting arranged for Mr Smith to give evidence before me. I formed a number of opinions and impressions as a result of the evidence that Mr Smith gave and the manner in which he gave that evidence.
28. As a result of that evidence, and also as a result of the material that Mr Smith has previously provided to the police, I find that the deceased began to act strangely shortly after the pair had arrived at Mr Smith’s residence. I find that they drank some alcohol and were talking. I find that the mood of Ms Hans changed whilst at Mr Smith’s residence. Mr Smith gave evidence that this occurred when he told Ms Hans that he could not come to her house that night. I find that not long after, the deceased asked for a pen and a piece of paper from Mr Smith, which he gave to her via his invoice book.
29. I find that the deceased wrote down 2 telephone numbers on that piece of paper. Those telephone numbers were for her de facto, Luke Furnell, and her mother, Korina Mansfield. I find that the deceased gave that piece of paper back to Mr Smith, but told him not to look at it until the following Sunday, being 28 October 2007.
30. I find that shortly thereafter the deceased left the residence and Mr Smith went into his accommodation. I find that only minutes later Mr Smith noticed vehicle lights at his residence and that this was just after 8.30pm. I find that Mr Smith went outside and discovered that the deceased had returned. I find that the deceased approached Mr Smith, kissed him on the cheek and said words to the effect “Thanks for listening to me”, and for being a good friend.
31. I find that Mr Smith believed this behaviour to be of concern and asked the deceased whether she wished for him to come back with her to her own residence. I find that the deceased said yes, and both she and Mr Smith got into the deceased’s vehicle and travelled out to Lot 1255 Leonino Road at Darwin River.
32. I find that during this trip the deceased drove in an erratic manner. Mr Smith gave evidence before me that as a result he asked Ms Hans to stop and she did so on a number of occasions. In addition during this journey the deceased wound down her window and threw her mobile phone out of the moving car and invited Mr Smith to do the same. He refused.
33. I find that prior to departing Mr Smith’s residence the deceased had requested to borrow a screwdriver from him, which Mr Smith gave to the deceased. I find that upon arrival at the residence of Lot 1255 Leonino Road, the deceased took out the screwdriver and entered the residence. I find that upon entering, the deceased asked Mr Smith to make her a cup of tea. I find that the deceased then went into her bedroom and was followed shortly thereafter by Mr Smith who saw the deceased begin attempting to open the gun safe located in the room with the use of the screw driver.
34. This gun safe belonged to Mr Furnell and contained 3 weapons belonging to him, namely:
a. 0.375 Lever Action Magnum;
b. 0.308 Rifle; and
c. 0.22 Rifle.
35. Mr Furnell had previously hidden the keys to the safe from the deceased due to an earlier incident where the deceased had used a gun in his absence. I find that Mr Furnell had done this because he was concerned about the deceased using his firearms in his absence whilst she was unlicensed.
36. I find that although initially Mr Smith believed it was not possible for the deceased to open the safe with the screwdriver, the deceased was in fact successful. Upon opening the safe I find that the deceased removed the 0.357 Lever Action Magnum and then proceeded to pry open the ammunition cabinet.
37. I find that the deceased and Mr Smith entered into a struggle with one another over the rifle and that Mr Smith was asking the deceased to let go of the rifle but she refused to do so. I find that the deceased eventually calmed down enough to the point that Mr Smith let go of the firearm. I find that shortly thereafter Mr Smith ran from the residence away from the deceased leaving her inside the residence with the weapon. As I stated during the course of the inquest that was a high powered rifle and a dangerous weapon, not just for Ms Hans, but for any other person.
38. I find that after leaving the residence Mr Smith began to attempt to communicate with his girlfriend, namely Ms Natalie Caviller, but that he could not initially get mobile reception. I find that he sent her text messages and also spoke with her requesting that she attend and locate him to take him home. I find that the first telephone call that Mr Smith made in this regard was at approximately 12.30am on Wednesday 24 October 2007.
39. I pause to note that it is extremely disappointing that Mr Smith behaved in the manner in which he did during his dealings with the police. There is no excuse for lying to police and no person should be encouraged in any way to lie to the police in their dealings. However I accept Mr Smith’s evidence that the reasons he lied to police were because (a) he was frightened of the reaction of his girlfriend, and (b) he was concerned that he would get into trouble with the police due to the fact that his “prints”, as he referred to them, were all over the firearm. I find that Mr Smith panicked.
Involvement of the Northern Territory Police
40. After Mr Smith left the residence I find that at approximately 1am on Wednesday 24 October 2007 police communications at Berrimah received a telephone call from a woman who stated that she had a gun and was going to kill herself and wanted someone to care for her dogs. During that first call the caller identified herself as Rebecka Shermaine Hans from Lot 1255 Leonino Road.
41. I find that Ms Hans told the operator that she had advised a friend that she was going to kill herself but that this friend had left as “he did not believe” her. I find that it is more probable than not that the male person that Ms Hans tells the operator she has told was Mr Smith. During this call Ms Hans also advised the operator that she had a boyfriend who was working on the oilrigs and identified him by name and stated that he would be returning to Darwin in 2 days.
42. I find that whilst talking with the police the deceased was crying and the telephone reception broke up on a number of occasions making the call extremely difficult. I find that the deceased indicated to the operator that the reason she was seeking the assistance of the police was because she was worried about her puppies being cared for upon her death and that she stated that she would shoot herself as soon as police arrived and she knew that the puppies were safe. The efforts of the police auxiliary on the other end of the telephone to the deceased are to be commended.
43. I find that at approximately 1.46am a further telephone call was received by police communications from the deceased asking when police were arriving. Unfortunately when attempts were made by the operator to further engage with the deceased the call was terminated by her.
44. I find that at approximately 1.50am police general duty members, namely Constable Marcus Lees and Brendan Berlin, attended at Leonino Road and established a forward command post approximately 1km from the residence. I find that at approximately 2am those Constables reported hearing a gunshot coming from the direction of where they believed the residence to be. I also note, from a number of civilian statements obtained by police, that some neighbours also heard a shot at approximately this time.
45. I find that at approximately 2.03am a further telephone call was received by police communications from the deceased asking when the police were arriving. During that conversation the deceased advised the operator that the gates to her property were unlocked and she simply wanted the police to come onto the property and get her dogs. I find that the deceased stated that she would let the police come onto the property and she would not hurt anyone but herself.
46. As an aside, I consider it important to point out that I consider that at all times the police communications operators, particularly the first operator, who spoke with the deceased during her telephone calls did absolutely everything they possibly could to try and engage with the deceased and to attempt to persuade her not to take the action that she intended taking. Unfortunately this was to no avail, but it is clear that this was not due to anything that the operators failed to do, or did not do in a proper and reasonable manner.
47. I find that at around this time the Watch Commander, Senior Sergeant Virginia Read, attended Leonino Road and took charge of the forward command post. Shortly after this, at 2.41am, negotiators were called in to assist with the situation and also to endeavour to communicate with the deceased.
48. I find that whilst undertaking duties at the forward command post, general duties members located Ms Natalie Cailler at approximately 2.57am driving her vehicle in the area. Ms Cailler stated she was trying to find her boyfriend, Luke Smith, who had sent her a text message stating that he was fearful of being shot and that he wished for her to come and get him from Leonino Road.
49. I find that in fact, shortly prior to Ms Cailler having been located by the police, the police had come across Mr Luke Smith walking in the area. When police initially spoke to Mr Smith he told them that he was in the area trying to locate a friend’s place on Leonino Road, but had gotten lost. He told the police that he had been there since about 12.30am. It appears clear that at that stage Mr Smith did not detail anything in relation to Ms Hans. I note that Mr Smith could not recall this earlier meeting with the police, however I accept the statements given by police in this regard and I find that this earlier interception did in fact occur.
50. As a result of the contact with Ms Cailler, and her description to them of her boyfriend, the police realised the connection and got in their vehicle and relocated Mr Smith, taking him with them back to Ms Cailler’s location. It appears that Mr Smith was again not frank in his further discussions with police on that second occasion.
51. As a result of the failure of Mr Smith to be open and honest with police, no direct link was made between he and the deceased at that time. This is particularly disappointing as I find that it is possible that Mr Smith may have had information that he could have provided to the police that could have assisted them in their negotiations and perhaps have had an impact upon police capacity to make a connection with the deceased. I cannot find that such information would have made a difference; just simply that it could have had an impact.
52. At approximately 4.40am the Darwin Greater Regional Commander, Kate Vanderlaan, was briefed and supported a request for the Territory Response Section (“TRS”) to be called out to support in the protection of police, and in particular police negotiators. At 5am I find that a high-risk support request was approved by Assistant Commissioner Mark McAdie who specified, as part of that request for the involvement of the TRS that they were to undertake inner cordon functions only whilst negotiators continued to attempt to contact the deceased.
53. I find that units from the TRS were informed to “sit it out” AND that the focus for the police at that time was on the protection of life for TRS and other persons and a directive was given that no deliberate action be taken without the direct approval of Assistant Commissioner McAdie.
54. It appears that very shortly after that approval was given, TRS members were called in between 5.30 and 6am. I find that after obtaining their gear and receiving an initial briefing, TRS travelled to Leonino Road. I also find that at approximately sunrise neighbours of the deceased were spoken to by police and provided information as to the possible employment of the deceased at Bluemax in Pinelands.
55. As a result, police negotiators attended at Bluemax and ascertained that the deceased did in fact work there as a welder and normally commenced duty at 7am. This was important information because at that stage it was unclear as to whether the deceased was still located at her residence. Given that the deceased was not at work, nor had she reported in sick, it was presumed that she was still located at her home.
56. I find that shortly after this information was obtained, police negotiators arrived at the scene at around 8am. This coincided with the arrival of TRS. Upon the arrival of TRS, the section members who were marksman, also referred to as “Sierras”, covertly approached the house and took up positions to monitor the residence and report back.
57. Initially there was no movement reported by the TRS members and it was still questionable, at that stage, as to whether the deceased was still located in the area. Police remained outside and continued monitoring the address noting that although there were air conditioners fitted to the residence, none appeared to be turned on.
58. I find that by the time TRS members had been able to get themselves settled into the area and able to properly report back as to what appeared to be happening at the residence, it was approximately 11am. It is not surprising that it took a number of hours for this to occur, given the terrain in the area and the location of the residence.
59. I find that at approximately 10.30am attempts were also made by police to once again communicate with the deceased via telephone, but these were unsuccessful. As a result a decision was made to utilize a speaker box with a wireless headset, which is commonly referred to in the materials before me as a “karaoke machine”. Police could use this machine by placing the speaker box close to the location of the deceased, but keeping the negotiators further away and out of danger.
60. I find that although the karaoke machine was placed in an area approximately 20 to 30 meters from the residence, the terrain in the area was such that a clear line utilizing the wireless communication could not be made with the speaker box without putting the negotiators and TRS members at risk. As a result the negotiators then began utilising the bullhorn or megaphone.
61. I find that the attempts via the bull horn or megaphone began at approximately 11.30am and that shortly after they were commenced, TRS first spotted the deceased at approximately 11.37am, where she was seen by TRS members to come out the front door and call out to her dogs to bring them inside. Although the TRS members could hear the negotiators clearly on the megaphone, the deceased was not seen to be responding or engaging in any way with the negotiators.
62. I find that attempts continued to communicate with the deceased utilizing the megaphone, but the deceased was not responding. I find that the deceased was seen on a number of occasions coming in and out of the door to the residence, but was not seen to be responding in any way to the attempts by the negotiators. The only noted response is that the deceased was seen to go back inside her residence and turn the stereo on in the house and turn the music up loud. I find that the deceased did this on a number of occasions.
63. It is plain from the documents tendered in evidence before me that all members of the police, but particularly the negotiators involved, namely Sergeant Leigh Cahill and Detective Senior Constable Neil Grant, acted in an exemplary fashion. I find that both officers Cahill and Grant did all that they possibly could to try and engage with the deceased in some way to prevent her taking her own life, or placing any other persons life in danger. It is clear to me that despite their very best efforts the deceased was extremely difficult to communicate with and appeared to be doing her best to ignore their attempts.
64. I note for the record that Sergeant Cahill was in court for a period of the inquest and appeared to be still extremely emotional about the events of that day. The death of Ms Hans was a tragic outcome, but it was not an outcome that appears in any way to have been caused, or contributed by, the actions of any member of the police. I hope that Sergeant Cahill and the other members find some solace in that.
65. I find that at approximately 1.20pm further communications were made with the mother of the deceased, Ms Mansfield, to try and discover information to assist the police negotiators. After that information was obtained, I find that from approximately 1.45pm onwards the police negotiators utilized information obtained from Mrs Mansfield to try and persuade the deceased to surrender herself.
66. It appears initially that the mention of the deceased’s mother was the first time that the deceased appeared to respond in any physical way to what the negotiators were saying. I find that during this time the deceased was seen by police at various stages to be crying or laughing to the things being said by the police to her about the relationship with her mother. The feedback about this was provided to the negotiators in a positive way and they continued in their attempts to have the deceased surrender by utilizing the information obtained from the mother.
67. Unfortunately it is also during this time that the deceased has come outside with a firearm in her possession. I find that at that stage the police were unable to positively identify the precise type of firearm that was in the possession of the deceased, other than it was a rifle. I find that on a number of occasions the deceased was seen to place that rifle beneath her chin, but would then pull it away.
68. I find that despite the very best efforts by the police negotiators, at 2.19pm on Wednesday 24 October 2007 the deceased placed the rifle beneath her chin and pulled the trigger sustaining a fatal wound.
69. Based on the autopsy report of Dr Terry Sinton, Forensic Pathologist, I find on the balance of probabilities that the cause of death for the deceased was a gunshot wound to the head. I find that the projectile from the firearm entered her head directly through the chin passing upwards through the base of her tongue and then through the hard pallet of the roof of her mouth. I find that the projectile then entered the nasal cavity, causing trauma to the midline third of the facial skeleton and continued directly upwards to enter the cranial cavity through the ethmoid plate, between the anterior cranial fossae. The projectile then passed directly upwards through the longitudinal fissure between the frontal lobes of the brain causing the noted brain damage and then exited the skull through the midline of the frontal bone, and the head through the stellate wound on the frontal scalp.
70. I find that shortly after firing that single fatal shot, the TRS marksman moved forward and observed the deceased lying with the rifle by her side. Paramedics were immediately called into the scene and began emergency treatment upon the deceased at approximately 2.24pm. I find the deceased was rushed to Royal Darwin Hospital and arrived at 3.28pm, but upon her arrival she was non-responsive and never regained consciousness. I find that Dr Didier Palmer declared Ms Hans deceased at the Royal Darwin Hospital at 3.30pm on 24 October 2007.
Findings and Recommendations
71. I am satisfied on the basis of the comprehensive and thorough police investigation, the exhibits and the oral evidence that I have heard at this Inquest, that the actions taken by the Northern Territory Police, including the Territory Response Section, was appropriate and their actions were conducted extremely well and in a timely fashion in what can only be described as clearly the most difficult of circumstances.
72. Mrs Mansfield gave evidence before me concerns with some of the actions taken by police and the decisions they made during the course of their dealings with the deceased and also with her. I note that in substance those concerns can be summarised as follows:
a. Why it took the police so long to communicate with her as to the events unfolding in Darwin when Ms Hans had written her contact details on a piece of paper that had been provided to the police;
b. Why it was that either she or friends of Ms Hans weren’t used by police to try and make a face to face contact with Ms Hans to broker a surrender;
c. Why it was that she was told her daughter has only suffered a facial wound from the firearm initially, believing therefore that her daughter would survive, and was then told that Ms Hans had in fact died;
d. Why it was that it took police some hours after the gunshot to actually advise her that Ms Hans had died;
e. Why it was that Ms Hans’ employer, Gill Rebecchi, had not been advised as to what was occurring when she was at the hospital waiting to see Ms Hans and she had already passed away;
f. Why it was that perhaps police didn’t have appropriate equipment to communicate with Ms Hans and were left to resort to the bullhorn or megaphone.
73. I note that both Detective Senior Sergeant Scott Pollock and Superintendent Robert Farmer gave evidence addressing these issues. It is clear on the evidence before me that the police did not have the piece of paper that Mrs Mansfield was referring to that had her telephone number on it. Although Mrs Mansfield believes that she was told the police had that number and had utilised it to communicate with her, I find that she is understandably mistaken in this regard and that such information was not provided to police until later on 24 October 2007 by Mr Smith, at which time Mrs Mansfield was already being spoken to by the police.
74. In terms of direct face to face negotiation with Ms Hans either by the police or by a third party, as I noted during the inquest, it was the situation years ago that police would go to the front door of a persons residence, even in these types of situations to try and calm a situation down. That is not the way of policing anymore. It is understandable that things have changed, particularly when you hear of situations, like the one referred to by Superintendent Farmer of police doing precisely that and being held in a hostage type situation for a number of hours.
75. Such direct confrontation places police, and any third party, in very real danger, particularly when the person involved has, as was the case here with Ms Hans, a firearm in their possession. In this case it was a high-powered rifle. Further, as stated by Detective Senior Sergeant Pollock and Superintendent Farmer, such direct action needs to be very carefully considered before any such action is taken so as to ensure it is not that very action that prompts the person to take their own life or that of another.
76. I acknowledge that it is very distressing that information was given to Mrs Mansfield that led her to believe that the injury suffered by her daughter was not life threatening. However I find that at that time, it is more likely than not that there was some confusion about the nature of the injuries suffered by Ms Hans and her capacity to survive, and that it is not unreasonable that when Mrs Mansfield is trying to communicate with police that there is some delay in providing her with precise information minute to minute.
77. As stated by Detective Senior Sergeant Scott Pollock, initially he too was advised that it was a facial injury that had been suffered and it was not clear if Ms Hans would survive, but that as soon as he was advised as to the real situation, he conveyed that himself to Mrs Mansfield. I note that it was a breach of policy for Detective Senior Sergeant Pollock to have done this over the phone, but I accept his evidence when he states that he did so, so that there were no illusions in the mind of Mrs Mansfield and her partner as to what was occurring.
78. In terms of the delay in providing such information I find that it is understandable that there was some delay particularly when it took over an hour to get the deceased from the scene to the hospital. During that time it was also necessary for there to be some debriefing of members who were extremely traumatised as to what had occurred. Such delay, although understandably distressing for Mrs Mansfield is not unreasonable given what had occurred, and I consider that police were doing all that they could in such circumstances.
79. In terms of the delay in advising Ms Rebecchi, I note that Detective Senior Sergeant Scott Pollock acknowledged that this was a failure in police systems and stated that he wished this had not occurred, but that there needed to be some clarification as to her relationship with Ms Hans and that contributed to the delay. I accept that the police have learnt from that experience as a result of their review and I intend to say nothing further on this point.
80. In relation to the concerns raised regarding equipment, I note that this has been considered by police during their own review and debriefing process. The only piece of equipment considered by police to have possibly made any difference whatsoever, if it had been available, was an armoured vehicle. I note Superintendent Farmer’s evidence that this is an extremely expensive piece of equipment that may only be utilised on a few occasions each year.
81. I also find the evidence given by both Detective Senior Sergeant Pollock and Superintendent Farmer regarding their opinion as to the events of this day to have been extremely important. Both officers are very experienced, long-term members of the police. Each officer indicated that taking into account their experience, and their understanding of police processes and policies, that everything that could have been done by police on this occasion was done, and that although it was an incredibly tragic outcome, in their opinion there was nothing the police could have done to change the outcome. As Detective Senior Sergeant Pollock stated, he would do it exactly the same way again.
82. I too have considered very closely the actions taken by police, and their policies that were tendered in evidence before me. I have no criticisms to make of the actions of the police in relation to this matter and consider that given the circumstances that they faced on this occasion, the actions taken by them were more than reasonable and appropriate. In fact I commend the actions taken in particular by the police negotiators who clearly endeavoured to do all they possibly could in the most difficult of circumstances. However it is clear that the deceased had decided on a course of action in terms of the taking of her own life and despite all reasonable endeavours by the police they were simply unable to alter that course.
83. In these circumstances I have no recommendations to make arising from the proceedings of this Inquest.

Dated this 10th day of October 2008
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GREG CAVANAGH
TERRITORY CORONER