RECORD OF INVESTIGATION INTO DEATH

Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4 

I, Rod Chandler, Coroner, having investigated the death of

Murray Leslie JOHNS

BY HOLDING AN INQUEST at St Helens on 26 and 27 March 2008 and at Hobart on 3 April 2008

FIND THAT :

Murray Leslie JOHNS ("Mr Johns") died on 18 September 2006. 

Mr Johns was aged 59 years. He was married and resided with his wife. Until shortly before his death he had been employed as a council supervisor. 

I find that Mr Johns died from a self-inflicted gunshot wound to the head.

At the time of his death Mr Johns was not being attended by a medical practitioner. 

EVENTS UPON THE DAY OF DEATH : 

Mrs Annette Vicki Johns is Mr Johns’ wife. At about 8.30 am on 18 September 2006 she left their home to go to work. Mr Johns was still in bed when she left. At about 11.30 am Mrs Johns returned. She could not locate Mr Johns, either in the house or in the garden. She opened the garage and saw her husband seated in a chair. A shotgun was between his legs. She feared that he was dead. She dialled 000 and shortly after a police officer attended. He was able to confirm that Mr Johns was deceased. Police carried out a general examination of the scene. There did not appear to be any suspicious circumstances. Subsequently, a post mortem examination was undertaken by Pathologist, Dr Donald Clark. He reported the cause of death to be "gunshot wound to head". 

CIRCUMSTANCES SURROUNDING THE DEATH : 

Background 

Up until 6 September 2006 Mr Johns had been employed by the Break O’Day Council as the supervisor of its Fingal depot. Mr Johns had been a council employee for 37 years, initially with the Fingal Council and after an amalgamation with Break O’Day Council.

As the Fingal depot supervisor Mr Johns managed a work crew comprising about 8 persons. Once of those was his eldest son, Andrew Gavin Johns. Another crew member was David Gordon Gillies who periodically relieved Mr Johns as supervisor when he was on leave. 

At the time of Mr Johns’ death the Council’s Manager was Brian Maxwell Inches. Its Works Manager was John Graham Cameron. At the time, the Council also employed engineer David Graham Klye. Mr Klye’s role was to co-manage, with Mr Cameron, the Council’s Works and Infrastructure Department. 

Malahide is a large pastoral property located at Fingal. Its manager is Ian Lachlan Herbert. 

The dismissal 

Mr Johns was directed to attend a meeting with Mr Inches on 6 September 2006. At that meeting he was handed a letter and advised that he was being summarily dismissed. The letter, omitting formal parts, states as follows: 

"I refer to your interview on Monday, 04 September, 2006 in the presence of Mr Graham Cameron and Mr David Klye. As part of that interview you were requested to answer a number of questions relating to your actions and the actions of the Fingal workforce in the previous week. 

As a result of those discussions and your answers I am aware that the timesheets relating to a drainage job in Cameron Street, St Marys had been falsified. 

I am also aware that the workforce falsely made entries on those timesheets to suggest that work had been carried out at Cameron Street, St Marys when in fact it had been carried out on the Malahide property. Your signature is endorsed on each of those timesheets. 

During interviews with the Fingal workforce each person who was interviewed advised that they had been instructed by you to make the false entries. This is confirmed by your own signature on those timesheets. 

The fact that you have instructed your workforce to carry out work not authorised by the Council and, that you have gone to some extent to conceal the issue is of grave concern. 

I believe that this action is so reprehensible that it constitutes gross misconduct warranting summary dismissal. 

I am therefore terminating your employment with the Break O’Day Council effective from close of business today and require that you return all Council property including the Council vehicle and both sets of keys by the end of work today. 

Your final pay will be forwarded to you tomorrow." 

Mr Johns took his own life 12 days after his employment was terminated. He did not have a history of depression or mental illness nor is there any evidence of family disharmony, financial difficulties or other personal trauma. These circumstances raise the question whether Mr John’s dismissal was a factor causative of his death? 

Events leading to the dismissal 

In early August 2006 a councillor referred to Mr Inches an undated and anonymous letter which he had received and which alleged that Mr Andrew Johns had been stealing fuel from the Fingal depot. It also alleged Andrew’s father had been complicit in this activity. (It was disclosed at the inquest that Mr David Gillies had been the letter’s author). Mr Inches had a staff member carry out an analysis of the time sheets of those workers at the Fingal depot. He then instructed Mr Cameron to take possession of the Fingal depot’s "Fuel Sheets" and to have them analysed with a view to detecting any anomalies. That analysis was undertaken by Mr Klye. In a statement provided to Tasmania Police Mr Klye reported that he had discovered some "curious entries" which he described in his statement as follows: 

"8. Recent fuel sheets seem to be different in appearance to older sheets. Recent sheets have a higher than usual number of entries by Andrew Johns, one of the "accused" employees.
9. Andrew’s entries are frequently for two small quantities of fuel together with fuel for a vehicle.
10. Machinery and small plant hours seem to match the fuel booked against each item, however, recently their usage is also inexplicably higher.
11. One entry shows 20 litres of fuel booked to the saw mill which has a tank capacity of about 10 litres.
12. One entry shows 15 litres booked to the forklift. The forklift has a tank capacity of about 50 or 60 liters and is used almost exclusively at the depot. The depot yard is small. This begs the question, why only put 15 litres in it if it is empty, or, why top it up if it is only down by 15 litres?" 

In the course of looking into the fuel issue Mr Cameron said that it came to light that some of the Daily Time Sheets submitted by some of the members of the Fingal crew were inaccurate in that they recorded work having been done on a drainage project at Cameron St. in St. Mary’s when in fact those workers had been undertaking "private works" on Malahide. It was Mr Cameron’s belief that Mr Johns had directed his crew members to falsify their time sheets. 

Mr Cameron reported to Mr Inches that the examination of the fuel records had revealed some anomalies. It was then decided that interviews of each of the workers at the Fingal depot would be carried out by Mr Cameron and Mr Klye and that the workers would be questioned individually upon their knowledge of any theft of fuel. At the same time it was decided that each of the workers would be questioned upon the apparent inaccuracies in their time sheets. 

The interviews took place at the Fingal depot on 4 September 2006. They were conducted by Mr Cameron and Mr Klye. Beforehand they had prepared a set of typed questions. The questions were put by Mr Cameron and Mr Klye made a written note of the answers.

 At the interviews several workers expressed their belief that Mr Andrew Johns had been stealing petrol. No such allegations were made against Mr Johns although Mr Gillies made the comment that "Murray has got to know about it." Mr Andrew Johns denied any wrongdoing. He was given a copy of the anonymous letter to read and then commented,. "I’m gobsmacked, someone here doesn’t like me." Mr Johns was also shown the anonymous letter and asked to comment. He said, ‘It’s a lot of rot. I don’t know anything about it." 

Five of the workers interviewed acknowledged that they had worked some hours at Malahide on the previous Tuesday and/or Wednesday (ie. 29 and/or 30 August) but that they had, on the direction of Mr Johns, completed their time sheets to show those hours as having been spent on the Cameron St. job at St Mary’s. Mr Johns was asked a series of questions on this subject. He acknowledged that some of his crew had worked at Malahide on the Tuesday and Wednesday. He was asked for detail of previous work done at Malahide and replied that "the last big job" involved some bridgework. It was noted that he explained that "this was done in return for logs-barter system and they let us dump rubbish and spoil on the property." Mr Johns also said that he showed on his own time sheet for the previous Wednesday that he had worked on the St Mary’s job for 8.5 hours and explained that he had spent this time travelling to Scamander and Campbelltown to secure materials. Mr Klye noted that this explanation "seemed reasonable to me." When it was put to Mr Johns that the time sheets were a fabrication he answered; "They were carting top soil for the job." It was also noted by Mr Klye that Mr Johns said; "We got heaps of soil for Cameron St. and other jobs." He was asked of his actual working arrangement with Malahide and replied that; "it started with Trevor, I spoke with Trevor about this and it was ok…..if they want something done I do it in exchange for topsoil, rock and bridge logs." (I understand "Trevor" to be Mr Trevor Berryman, the Council’s previous Works Manager). Finally, Mr Johns was asked why he concealed or disguised his relationship with Malahide and he replied; ‘I never took it that way. I don’t hide anything." 

Mr Cameron then proceeded to immediately suspend Mr Johns on full pay. He explained what he told Mr Johns at the time in these terms; 

"….I said that in view of the serious nature of the allegations about the fuel and the fact that there was a police investigation current into them…, I said that because of that and that fact that, yeah, I couldn’t trust him because he’d deliberately flouted a work instruction by going to Malahide when he’d agreed that he could do the Cameron St job I stood him down and said that we’d have to have a meeting with the general manager to resolve the matter, because at that time I just really didn’t know how we were going to resolve the fuel one when the police were involved and so I wasn’t sure what to do." 

Although the fuel issue was a factor in his decision to suspend Mr Johns, Mr Cameron did not, paradoxically, suspend Mr Andrew Johns although he was alleged to be the principal offender. 

Mr Cameron and Mr Klye reported back to Mr Inches on the interviews with the Fingal work crew. They provided him with copies of the written questions with each interviewees’ responses noted. Mr Inches was told that five of the workers had acknowledged that something was amiss with respect to the fuel. According to Mr Inches he was not made aware at this time that Mr Johns was denying the fuel allegations by describing them as "rot". It seems that it was at this time that Mr Inches determined to formally refer this matter to Tasmania Police for its investigation. 

As to the matter of the time sheets Mr Cameron informed Mr Inches that Mr Johns had not provided him with a satisfactory explanation for his action in assigning several of his crew to work at Malahide on the previous Tuesday and Wednesday when they should have been working on the St Mary’s job nor had he satisfactorily explained his conduct in directing the workers to show on their time sheets that these hours had been worked at St Mary’s and not at Malahide. 

It was the evidence of Mr Herbert that in the late afternoon of 4 September 2006 he was telephoned by Mr Johns who informed him that he had been stood down that day because he had charged to the St Mary’s job private works which had been undertaken by some of his crew on Malahide during the previous week. The following morning Mr Herbert ‘phoned Mr Klye because he was concerned that the events surrounding Mr Johns’ suspension may impact upon the good reputation of Malahide. Mr Klye said that he intended to visit Mr Herbert that day to discuss the matter. At about 10.30 am. Mr Klye and Mr Cameron arrived at Malahide. I need to observe at this point that Mr Herbert’s account of the meeting differs in some respects from the account given by Mr Cameron and to a lesser degree by Mr Klye. In my opinion Mr Herbert was an impressive and credible witness. I prefer his evidence to that of the other attendees where it differs. 

At the Malahide meeting Mr Herbert explained his understanding of the arrangement that he had with Council whereby he provided topsoil, rocks and logs in return for the Council carrying out some small private works. He said that he had told Mr Johns, consistent with this arrangement, that some repair work needed to be done on one of Malahide’s bridges and that Mr Johns had said to him that Council "needed soil for the St Marys’ footpath job and that would work out well." No precise date was set for this work to be done but Mr Herbert confirmed that during the last week of August some of Mr Johns’ work crew attended at Malahide and removed some topsoil and carried out the bridgework. 

It was Mr Herbert’s evidence that at the meeting on 5 September Mr Cameron talked of Mr Johns in very derogatory terms describing him as "an ignorant pig," "king shit" and that he needed to be "knocked off his pedestal." Nevertheless, Mr Herbert was told that Mr Johns would not be dismissed and that his salary and other conditions would remain but that he would lose some of his work responsibilities. 

On the evening of 5 September Mr Herbert advised Mr Johns that he had been told by Messrs Cameron and Klye that he was not going to lose his job. 

Meantime, following his meeting with Mr Cameron and Mr Klye, Mr Inches was inclining to the view that Mr Johns’ conduct was sufficiently serious to warrant his summary dismissal. He accepted that Mr Cameron and Mr Klye had suggested to him that one option was to demote Mr Johns and transfer him to the St Helens’ depot. However, Mr Inches did not consider this course to be sufficiently severe. He then telephoned Ms Sharyn Haas, an employee of the Tasmanian Chamber of Commerce and Industry (TCCI), and sought her advice. Mr Inches was closely cross-examined upon the content of this conversation, particularly with regard to his understanding of Mr Johns’ misconduct. The cross-examination included this exchange: 

"Mm. I turn now to the Cameron Street job issue. When you sought Sharon Hayes advice, you told her that it had been established that Murray Johns had, first of all, disobeyed Graeme Cameron’s instruction to proceed with the Cameron Street job, right?...Yes. 

And that was you view. You thought that had been established, didn’t you?...Yes. 

Secondly, that Murray Johns had deployed his crew on an unrelated private job at Malahide, correct?...Yes. 

Nothing to do with Cameron Street?...No. 

Private work for Malahide, private benefit or private job for a mate, is that right?...Yes. 

That was your view, wasn’t it?...Yes, it was. 

And you were satisfied, thirdly, that Murray Johns had falsified his own timesheets and he instructed his crew to do the same?...Yes. 

And you were satisfied that the reason he did that was to cover up for the fact that he was doing a private job instead of what he was supposed to be doing, right?...Well, I couldn’t answer that last - I believe that’s the case but whether that was in his mind, I don’t know. 

 That’s what you believe - it was the purpose of it though wasn’t it?...Yes. 

Because that’s why you thought it was fraudulent, right?...Yes, and that was the basis of the dismissal. 

Yes, I appreciate that. Thank you for your frankness. In your mind there was no doubt that there was fraudulent activity and that’s why you decided to proceed on that basis?...Yes. 

Yes. And you believe the reason he was covering up the private work was because there was some form of private gain in it for him or for someone else? Or a straight disobeyance of standard procedures. 

Um, you believed that it was unrelated to his council duties though, his council work - that is, what he was doing at Malahide?...It was private work for Malahide, yes. 

Unrelated to what his responsibilities were as a council employee?...Well, on that occasion, yes, definitely. 

And I’m only talking about that occasion. So, you thought he was effectively using council employees and council equipment for what was effectively private business of his own?...Yes and I’m still of that opinion. 

Yes, okay. When you came to the decision that Murray Johns should be sacked, it was your understanding wasn’t it, that all of those allegations had been put to Murray Johns and he was unable to give any clear or coherent explanation of his actions, is that right?...We gave him the chance to provide comment but he didn’t choose to provide that. 

In fact what you believed was that he’d been asked about those matters during the interview by Graeme Cameron and David Klye and he had been unable to give any coherent or satisfactory explanation, right?...Yes. Coherent or satisfactory, yes. 

In fact, isn’t it true that what Graeme Cameron told you was that he had been unable to give any clear or coherent explanation of those matters?...Yes. 

……………………………………………….. 

Right. It was you understanding, wasn’t it, when you made the decision to sack Murray Johns that he did not dispute the truth of these allegations that were made against him in these things you believed, right?...Yes." 

Upon the basis of the information provided to her, Ms Haas advised Mr Inches that Mr Johns’ misconduct was significant and warranted his summary dismissal. 

By 6 September Mr Inches had made the decision to terminate Mr Johns’ employment. A meeting was set for that afternoon. Mr Gillies was assigned to call on Mr Johns to advise of the meeting and to request him to attend. At the meeting Mr Inches was present along with Mr Cameron and Mr Klye. Mr Johns was unaccompanied. Mr Inches informed Mr Johns that he was aware that the Fingal crew had worked at Malahide without Council approval and contrary to his supervisor’s instruction. He said that he was also aware that time sheets had been falsified to disguise the true situation. According to Mr Inches, he asked whether Mr Johns could provide an explanation? When he replied "No" Mr Inches proceeded to inform Mr Johns that he considered his actions amounted to gross misconduct which warranted his summary dismissal. Mr Johns was then given the letter of dismissal and told that his employment was terminated. 

On 7 September Mr Herbert met with Mr Inches and Mr Klye at Malahide. The meeting had been requested by Mr Klye as Council wished to formalise its future dealings with Council and bring to an end the more casual arrangement under which Mr Johns had operated. Subsequently Mr Klye wrote to Mr Herbert setting out the terms of the new arrangement. In that letter Mr Klye acknowledged that Malahide had provided Council with 150 cubic metres of topsoil in late August 2006 which had a commercial value of $1650. At the same time the letter recorded that Council had provided Malahide with labour for bridge repair work at a cost of $1636.10. In other words there had been a near equal barter between the parties. 

It was Mrs Johns’ evidence that in the days immediately following his dismissal her husband was particularly concerned about its effect upon his superannuation. He feared that because he had been summarily dismissed he would be disqualified from receiving his superannuation benefits. Mrs Johns contacted the superannuation fund and they later were advised by ‘phone that Mr Johns’ entitlements would be unaffected. However, Mrs Johns was not sure that this advice completely reassured her husband. It was Mrs Johns further evidence that she noticed changes in her husband during the second week following him finishing work. She said that at this time "he just went very very quiet and within himself…" She noticed that he lost his appetite and over the two days before his death "he was quieter still."

Mr Herbert also had contact with Mr Johns in the days following his dismissal. He described him at this time as being "depressed" and "irrational" and having lost interest in his small farm and his stock. 

Some other relevant matters

Mr Herbert had been employed at Malahide for 4.5 years, the last 1.5 years as manager. In an affidavit provided to police he describes his understanding of a barter arrangement involving Malahide and Council in these terms: 

"Since I have been at Malahide I have had an understanding that an agreement existed between Malahide and the Break O’ Day Council which involved the Council obtaining rocks, soil and trees from Malahide to use in their works throughout the Municipality. Malahide allowed the Break O’ Day Council to dump large amounts of landfill on the property to save them the time and expense of transporting the fill to where it would normally have to go. Malahide would also assist the council from time to time in other matters such as the use of farm machinery to move trees that had fallen across public roads and the like. All of these things were provided free of any charge and in return the Break O’ Day Council would attend to some jobs on Malahide without billing the cost to the property. These jobs would take the form of using a council backhoe to dig some holes, assist in repairing a culvert or a small bridge or the like and were not billed to the property. 

"The council also did jobs on the property that were paid for by Malahide, the smaller type of jobs were taken care of under the agreement that was mentioned earlier. In short we assisted the council and the council assisted us. I believe that Council and Works Managers were fully aware of this arrangement as I believe that it would be impossible to be unaware of the quantities of material that were coming off Malahide and being used on Council jobs throughout the Municipality without invoices being received." 

It was Mr Cameron’s evidence that he was aware that an arrangement had been in place involving Council and Malahide which dated back to the time of his predecessor but that he had "never gone into it in any great depth". He said that he "assumed" it to be "fairly low key" and that he had not been aware that "it was quite the industry it turned out to be." According to Mr Klye he was unaware of the existence of any contra or barter arrangement involving Council and Malahide. Mr Inches was similarly unaware. 

In May 2006 rehabilitation works were carried out on the rivulet at St Marys. Mr Klye was Mr Johns’ supervisor for this project. The job required a large quantity of rock which was to be sourced from other works on the Esk Highway. That source was exhausted before the project was finished. Mr Johns obtained the additional rock from Malahide although it was Mr Klye’s evidence that he had no recollection of that fact. Mr Herbert estimated about 100 tonnes of rock was taken which represented about 10 truck loads. Malahide did not render an invoice to Council for this material. 

As I have indicated above, Mr Johns, when he was interviewed on 4 September, explained that his workers’ time had been charged to the St Mary’s job because they were at Malahide to collect topsoil for that job and for others. In all some 15 truck loads of soil were taken. It was Mr Cameron’s evidence that 2 to 3 loads only of top soil would have been required for the job at St Marys. He described as "crap" the explanation given by Mr Johns because the amount of soil collected was grossly in excess of the amount required for the St Mary’s job. 

It was Mr Klye’s evidence that on 3 to 4 occasions he advised Mr Johns that it was necessary, "to facilitate accurate costing and estimating," that time sheets be accurately completed. 

Sometime in 2002 or 2003 Mr Cameron issued a memorandum to all supervisors including Mr Johns directing that no private works be undertaken which involved a cost greater than $500 without first obtaining his authority. It was Mr Klye’s evidence that this was "an old memo rather than a council policy" and that the policy existing in 2006 required that all private works be the subject of a private works order including those of a value less than $500. In contrast it was the view of both Mr Inches and Mr Cameron that private works of a value less than $500 could be undertaken at the supervisor’s discretion and without requiring his authority. 

I have set out above that portion of Mr Klye’s statement made to police which describes those "curious entries" which caused him to suspect that Mr Andrew Johns had been stealing fuel. He was closely cross-examined upon these "entries." It is not necessary that I set out the detail of that cross-examination. Rather, it is sufficient for me to note that Mr Klye, very reasonably and properly, acknowledged that in some instances there were probable and innocent explanations for some of the "curious entries." In other cases he accepted that he had made some errors in his analysis of the material. In the result, his evidence of those apparent anomalies which had initially caused him to suspect Mr Andrew Johns of wrongdoing, and by association his father, was significantly devalued. 

Within a short time of the fuel issue being reported to police by Mr Inches, Council was informed that the information provided by them was insufficient to warrant an investigation being commenced. The matter was not taken any further. The police did not seek to interview either Mr Andrew Johns or his father. It seems that although Council was advised that the police did not intend investigating the fuel issue no-one at Council informed either Mr Johns or his son Andrew of this decision. 

Mr Johns’ last performance review took place in August 2004. At that time the employer did not record any dissatisfaction with any aspect of Mr Johns’ work. Mr Inches noted at the time "Well done Murray. You’ve carried out your duties effectively and efficiently." 

Council did not have in place in 2006 any process for employees who may be at risk of stress to receive counselling assistance. Mr Johns was not advised of any counselling service that he may have accessed, if required, following his dismissal. Since, and probably because of Mr Johns’ death, Council have entered into an arrangement with a counselling service for it to provide counselling assistance to employees who may be at risk of a stress-caused illness as required. 

FINDINGS AND COMMENTS 

The evidence, in my opinion, overwhelmingly compels the conclusion that Mr Johns’ death on 18 September 2006 was a direct consequence of his summary dismissal occurring just 12 days previously. 

It is my further opinion that Mr Johns’ summary dismissal was not warranted and that it came about because of a complete misunderstanding on Council’s part of the circumstances surrounding the work undertaken by Mr Johns’ work crew on 28/29 August 2006. 

When Mr Johns was interviewed by Mr Cameron and Mr Klye on 4 September he made it known to them that the work being carried out by his crew members at Malahide on 28 and 29 August was in accord with a barter or contra arrangement that Council had in place with Malahide. Mr Cameron described this explanation as "crap." When he and Mr Klye reported back to Mr Inches, they advised him that Mr Johns had not provided a satisfactory explanation for his conduct in directing his men to work at Malahide and subsequently having their time sheets completed to indicate that they were working on the Cameron St job at St Marys. This was a serious error on the part of Mr Cameron and Mr Klye. Having heard Mr Johns’ explanation it was, in my opinion, incumbent on them, before they provided a report to Mr Inches, to fully investigate the arrangement with Malahide. Had they done so they would have discovered that: 

As I have noted above, Mr Inches accepted, when cross examined, that it was his belief when he sought the advice of Ms Haas from TCCI that Mr Johns had, on 28/29 August, been using council workers and council plant for his own private purposes and that he had sought to cover up his actions by falsifying the time sheets. Had Mr Inches been fully aware of the arrangement with Malahide he would have understood that Mr Johns was not utilising Council labour and plant for his own purposes on 28/29 August but rather was engaged on work for Council’s benefit. Too, he would have appreciated that portion of the topsoil recovered from Malahide at that time was to be used for the Cameron St works and it was thus not entirely inappropriate for the labour costs associated with the collection of that topsoil to be charged to the Cameron St job. Certainly, a proper investigation would have shown that there was no basis for Mr Inches having the belief that the timesheets had been falsely completed to disguise any wrongdoing by Mr Johns. 

If Mr Inches had been fully aware of the true situation with Malahide then I am certain that he would have appreciated that Mr Johns’ dismissal was not appropriate and that the situation could have been adequately addressed by directing Mr Johns to discontinue the arrangement with Malahide and by putting in place a process (as he in fact did) whereby Malahide was, in the future, required to provide Council with an invoice for all materials and services provided to Council and Council in turn would provide an invoice to Malahide for all private works undertaken at its request. 

I need to observe that Mr Inches was provided with copies of the written document detailing the questions put to Mr Johns at his interview and his answers. It is not clear from the evidence whether he read this material. If he had done so it would have been apparent to him that Mr Johns was asserting that the work done at Malahide was in accord with the barter or contra arrangement. Mr Inches’ failure to read this document, or if he did, to direct that the Malahide arrangement be more fully explored, was symptomatic of a readiness by Council to assume wrongdoing on Mr Johns’ part and to deal with the matter with undue haste. 

SUMMARY 

1. Mr Johns died on 18 September 2006 from a self-inflicted gunshot wound to the head.
2. Mr Johns’ death was a direct consequence of his summary dismissal by the Break O’ Day Council on 6 September 2006.
3. Mr Johns’ dismissal was unwarranted. It arose because of a failure on Council’s part to properly investigate and understand the circumstances surrounding the work undertaken by Mr Johns’ work crew on 28/29 August 2006.  

I conclude by extending my sincere condolences to Mrs Johns and her family for their tragic loss.

Dated the 2 July 2008.   

Rod Chandler
CORONER