Record of Investigation into Death (Without Public Inquest)
Coroners Act 1995
Coroners Rules 2006
Rule 11
I, Glenn Hay, Coroner, have investigated the death of
BILLY JOHN GRICE
I have decided not to hold a public inquest hearing into his death because my investigations have sufficiently disclosed the identity of the deceased person, the time, place, cause of death, relevant circumstances concerning how the death occurred and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1999. I do not consider that the holding of a public inquest hearing would elicit any information further to that disclosed by the investigations conducted by me.
I find that:
a) Billy John Grice (I will refer to him by his Christian name of ‘Billy’) was born on the 3 August 1993 and on 24 May 2010 was aged just 16 years.
b) Billy died on 3 June 2010 at the Royal Hobart Hospital.
c) Billy was single and was employed as an apprentice at the time of his death.
d) Billy died as a result of a swollen brain and consequential pneumonia due to closed head injuries received in a single vehicle motor vehicle accident and that occurred on 24 May 2010.
Background:-
Billy lived at home with his parents and younger sister on the family farm at Richmond. It is very clear that he was a much loved and very loving young man. When he was 14 years of age he was diagnosed with Tourette’s syndrome but as time went on it caused little concern and otherwise he was in good health.
In March 2010 Billy obtained an apprenticeship at O’Brien’s Joinery in Glenorchy and he was very happy with his job and enjoying earning his own income. He was doing very well in his apprenticeship and loved going to work.
Having grown up on the family farm and helping his father on a daily basis, he loved machinery and cars and had been driving since the age of 8 years. In about November 2009 Billy obtained his learner driver licence and at about the same time his parents bought him a 1998 model white Commodore motor vehicle. It was registered in his father’s name, but it was considered Billy’s car. The Commodore was in very sound mechanical condition and was lovingly cared for by Billy. He loved driving and was very keen to drive on the road and drove at least 4 hours each week being supervised by one of his parents or sometimes a friend. Billy’s father (‘Shane Grice’) regarded his son as a very good and cautious driver for his age as he had no inclination to take any risks. Both of his parents were of the belief Billy would never drive his vehicle without one of his parents being present.
In April 2010 Billy sat for his ‘L2’ driving test but was not successful as he had failed to use his rear-view mirrors sufficiently.
In about November 2009, Billy met a young woman about his age (‘Kaitlin’). They started dating in about early April 2010 and spoke every night by telephone and also sent many text messages each day. From all available evidence it is clear that Billy and Kaitlin had a close friendship although Billy was aware from discussions with his parents that they were not happy about it and he took steps to minimise his parents’ exposure to it.
It is also clear from the observations of his parents and by Kaitlin that for some weeks prior to 24 May 2010 he was unhappy and stressed about his parents’ reaction to his relationship.
Circumstances :
From all available evidence and subject to any qualifications or concerns noted, I am able to make the following findings of fact.
On 24th May 2010 Billy and Kaitlin met in a restaurant in Glenorchy after Billy’s work and before Billy’s mother picked him up at about 3.30pm to take him home. That evening, Shane Grice observed Billy appeared happier than he had done in the past few weeks and “was a bit more like his usual self.”
Kaitlin went to stay at her friends’ house at 570 Baskerville Road, Old Beach. Billy had informed her that he was going to either stay at the home of a work colleague at Claremont or his cousin’s at Brighton that night.
Kaitlin and Billy exchanged numerous text messages later that afternoon and evening and they mutually arranged that Billy would come to see her after his parents had gone to bed. It was arranged they would meet at the end of the long driveway at 570 Baskerville Road.
It is clear that Billy was very nervous about his parent’s reaction if they became aware of his intentions. He had parked his Commodore in an area so that his parents would not hear it leave. He also left a note at home to say he had gone to stay at a friends place.
Billy left his parents home at about 10.45pm and arrived outside 570 Baskerville Road at about 11.06pm. Kaitlin walked down to his car which was parked on the side of the road. They talked in his car for about 15 to 20 minutes and it was clear to Kaitlin, that Billy was maybe a little frightened of what his parents might say if they found out. Kaitlin believes she left Billy about 11.45pm. He did not drive off immediately as he sat in the driveway with the headlights on so that she could see where she was going. She did not see him drive off and she did not see or hear from him after that. She sent him subsequent text messages and attempted to call him but received no reply.
At about 11.30pm/11.40pm Mr Millar, a resident of Honeywood Drive, about 2 to 3 kilometers from 570 Baskerville Road was driving home. Mr. Millar observed a white Commodore parked on the opposite side of the road in the vicinity of the driveway to 570 Baskerville Road. It had no external lights on but the interior light was on and he observed the driver was leaning over towards the passenger seat and was wearing a dark hooded top. Mr. Millar believed this was either suspicious or the driver was having car trouble and so did a u turn. As he approached he observed that the Commodore had done a U turn, heading towards him in the direction of Bridgewater. They passed. Mr. Millar again did a u turn heading home but via Cove Hill Road so as to go to a service station to get fuel.
As Mr. Millar proceeded along Cove Hill Road he observed the white Commodore heading along Briggs Road towards Brighton and it pulled into a driveway but immediately reversed out and headed back towards Baskerville Road. Again Mr. Millar’s suspicions were aroused and he again executed a U turn and followed the Commodore into Baskerville Road. Mr. Millar drove into a driveway about 50 meters from 570 Baskerville Road. He exited his vehicle and walked a short distance to a crest in the road and saw the Commodore had again parked in the same spot where he had first observed it. He was still suspicious believing the Commodore was about to be burnt out. He telephoned police at 11.41pm.
It is clear that the white Commodore was Billy’s and it is more likely than not that Mr. Millar’s observations of its movements occurred after Kaitlin and Billy had parted company that night.
Senior Constable Deutschbein as driver and his passenger Constable Francombe were tasked to investigate in police vehicle N33. They were in uniform and the vehicle was marked. They entered Baskerville Road from Briggs Road and traveled in a general southerly direction.
The supervisor of the two officers, Sergeant Semmens was also advised of the incident and he entered Baskerville Road in a northerly direction from East Derwent Highway, or the Old Beach end. He was driving marked police vehicle N32.
At about 11.55pm N33 drove past Mr. Millar from the Briggs Road direction. Mr. Millar then reversed out of the driveway in which he had parked and drove to the crest in the road, stopped and observed the police vehicle parked behind the Commodore which was parked on the verge outside 570 Baskerville Road, facing south and with its lights off. He observed S/C Deutschbein exit the passenger side of N33 and walk towards the Commodore. Before the PO had reached the Commodore, Mr. Millar observed the Commodore drive off in the direction of Old Beach with wheels spinning and leaving a cloud of dust. He observed the PO hurry back to the PV “which took off after the Commodore”.
It is to be observed that Mr. Millar’s observations were at night with no street lighting and from 50 meters away.
It is the evidence of the two police officers that S/C Deutschbein exited N33 and approached the drivers window and tapped on the window and said “It’s police” and at that time the young male driver, without looking at the officer, started the vehicle and drove off accelerating rapidly and at this time the headlights on the vehicle came on. On this discrepancy in the evidence about the PO approaching the Commodore, I prefer that of the police officers given Mr. Millar’s position of observation.
N33 followed. S/C Deutschbein advised Radio Dispatch Services of the registration number of the Commodore and that the vehicle “had just taken off on us”.
Mr. Millar followed the Commodore and N33, although at some distance behind.
Billy’s vehicle accelerated to an increasing distance from N33 and the police officers observed it pass Sgt Semmens oncoming PV and heading up a slight hill in the distance. N33 continued to follow and passed oncoming N32 and at that point observed Billy’s vehicle at the crest of a hill beyond a straight stretch of road. N33 continued on and found Billy’s vehicle stationary in a ditch above a culvert in the middle of a right hand bend just beyond the intersection with Yellow Brick Road.
It is the evidence of the police officers that they then activated the emergency lights on N33 to warn other motorists and S/C Deutschbein approached Billy’s motor vehicle and found the engine not running but the headlights still on. The driver’s side window was smashed and there was apparent damage to the right side of the vehicle. Billy was slumped down to the right and was found to be unresponsive although he had a pulse. He had apparent injuries to the right side of his head. According to the two police officers, Billy was still wearing his seatbelt and airbags had not been deployed. The vehicle was automatic and in drive and the handbrake was off. A short time later Sgt Semmens attended at the crash scene as did Mr. Millar.
Emergency services were called and Billy was transported to RHH in a critical condition. From all of the evidence it is clear that in the crash he received severe closed-head trauma when his head came into contact with windows or other solid parts of his motor vehicle.
During the next 10 days Billy received maximum medical management, sedation, ventilation and neuro-protective measures. Decompression craniotomy was considered but found to be medically inappropriate. Despite full measures including dialysis, his cerebral oedema did not resolve and his condition deteriorated. He died at 3.20 pm on Thursday 3 June 2010, in the proximity of his loving family.
Dr Christopher Lawrence, State Forensic Pathologist performed an autopsy and it is his opinion that a swollen brain with closed head injuries with consequential pneumonia was the cause of death. I accept that opinion. I also find those injuries occurred in the crash on 24 May 2010.
THE CRASH INVESTIGATION AND THE ISSUE OF POLICE MOTOR VEHICLE PURSUIT POLICY OR ALTERNATIVELY WHETHER THE CRASH OCCURRED WHILST BILLY WAS IN ‘POLICE CUSTODY’:-
I have considered carefully the evidence available to me and whether I should hold a public inquest hearing to air any issues arising from the actions of police in following Billy’s vehicle and whether those actions may have caused or contributed to his crash and his consequent death. For that reason the background evidence and my findings are more detailed than might otherwise be the case.
I find there is no evidence to suggest Billy was immediately before his death a person held in police custody or under the control of a police officer, or died whilst attempting to escape from such custody.
I find for the reasons following that the actions of police following Billy on this night did not cause or contribute to his death.
Because of the possibility of issues arising from Billy’s death, such as whether police properly adhered to reasonable pursuit policies and/or whether there may be a deemed ‘death in custody’ arising from the actions of police, Tasmania Police conducted extensive internal inquiries into the circumstances surrounding the crash. I have had the benefit of very comprehensive reports and sworn affidavit material arising from the initial crash and circumstances investigation by Crash Investigations Services as well as a detailed review by then Acting Inspector John Ward, followed by an even more detailed and comprehensive review by Inspector M Fogarty of the Tasmania Police Management Review Division of the Professional Standards Unit.
While those reports and details of investigations and reviews have contained certain results, findings and recommendations that have been of significant assistance to me, it is for me to make determinations about the appropriateness or otherwise of the role of police and the appropriateness of their policies in and about this unfortunate death.
By Section 24(1) (e) of the Coroners Act 1995 I must determine whether Billy’s death occurred in the process of a police officer attempting to detain him. He died 10 days following the events of the evening of 24 May 2010.
Section 93 of the Police Service Act 2003 mandates the Commissioner of Police to publish a Police Manual containing orders, directions, procedures, instructions and other appropriate things. As a result the Tasmania Police Manual (TPM) is published for all police officers and it contains (among other things) relevant policies, orders and directions that relate to pursuits.
I accept that Tasmania Police operates under a ‘restrictive pursuit’ policy rather than a ‘no pursuit’ policy and it is aimed at placing limitations on the level of discretion of police officers, imposes restrictions on the circumstances for which pursuits are permitted, as well as specifying the procedural requirements for police officers whenever they are involved in pursuit incidents. The rationale for the pursuit policy is to highlight that there are safety risks to the public and police officers when police engage in pursuit, particularly when high speeds are involved. The policy recognises that police have a duty of care to the public and to other police officers. Unless otherwise properly authorised, police officers are to comply with speed limits and other traffic rules. Authority may be provided in instances such as an emergency involving obvious and immediate danger to human life or the detection or prevention of a serious crime as specified in Appendix B of the Criminal Code 1924 and robbery - TPM 14.20.4
The definition of ‘pursuit’ is found in the TPM 14.20.3 - ‘an attempt by a police officer driving a motor vehicle to intercept a person driving another motor vehicle who, by their actions, has indicated an intention to avoid interception. These actions can include high speed driving, evasive tactics, or wilfully disobeying a direction by a member to stop. This definition includes pursuits at all speeds and over any distance, and does not necessarily involve speeds in excess of prescribed speed limits.’
The stated objectives behind the policy are (among others) - to minimise risks associated with the use of police vehicles and to impose mandatory procedures in the event police officers are permitted to sustain speeds in excess of prescribed speed limits or engage in pursuits.
TPM 14.20.5 and 6 – ‘police officers who engage in urgent duty driving not arising from a tasking/allocation by Radio Dispatch Services (RDS) or otherwise engaged in a pursuit, shall immediately notify RDS of the reason for the urgent driving, and that emergency warning equipment has been activated and in the case of a pursuit provide a running commentary of the progress of the incident. RDS is to monitor and assess the risks of any pursuit and terminate if necessary.’
In certain circumstances the policy allows for police to follow a vehicle after they have ceased ‘pursuing’. An example of this would be in the interest of public safety. In these instances, police must deactivate their emergency signals and observe all road rules, most particularly speed restrictions.
However, it is clear to me that police policies do not dictate that police officers should pursue at speed with emergency lights activated or not in an attempt to intercept or obtain details of a motorist for failing to engage with a police officer merely following a tap on a car window and uttering the words “it’s police”.
In this case, could it be said any of the Police Officers were attempting to detain Billy?
I find that the distance between 570 Baskerville Road and the crash site to be approximately 2.5 kilometers. Detailed analysis of police records including radio transmission and GPS-type tracking records disclose that the total time of driving between those two places was something less than 95 seconds, but more likely to be just greater than 85 seconds.
An accident scene investigation was undertaken by very experienced officers, Constable Cordwell and Sgt Carrick of Crash Investigation Services. I accept their findings and adopt them. At the time of the crash, Baskerville Road was subject to the default open road speed limit of 100km/h and the sweeping bitumen curve at the place of the crash was governed by a speed advisory sign of 45km/h on either end of the curve. It was found that the maximum speed for a vehicle to negotiate the curve at the place of the crash without commencing to slip and rotate around a vertical axis with loss of control is 81km/h. Visible tyre scuff marks on the western side of the road (in the north bound lane) commenced 35 metres north from the crash site. The marks were consistent with a vehicle traveling in a southerly direction rotating clockwise around a vertical axis and having rotated over 180 degrees. Those marks indicated the vehicle was at an angle of 50 degrees to its normal path of travel at the commencement of those marks but clearly loss of control had occurred well north of those visible marks. The loss of control by way of clockwise rotational movement was clearly as a direct result of excessive speed.
The only other relevant witness to the events of that night is Mrs. Hitchens who lives approx 500 meters west and 200 meters south of the crash site. It is her evidence that at about 11.40pm she was in bed and lightly sleeping when she “heard a car go very fast along the road and the next probably two seconds afterward I heard an almighty crash…. I picked up the phone beside my bed and rang triple 0 and looked out my bedroom window or the blinds and I could see two cars coming in the direction of Briggs Road or Brighton way”. It is her evidence that from the noise of the first car it was traveling at a very fast speed and it went passed her house “towards Briggs Road or the Yellow Brick Road, or out towards Brighton.”
On this evidence it can only be Sgt Semmens car that she heard traveling at the very fast speed. On all other evidence it is the only vehicle traveling in the direction she believed she heard the noise. Her evidence of “probably only two seconds afterward I heard an almighty crash” is not plausible if the evidence of the police officers is to be accepted. It is possible that awaking from a sleep her perception of time may have been misjudged, but I can make no finding about that. All I can say is that I have the evidence of 3 police officers that the gap between Billy’s car and any pursuing vehicle was 500 to 600 metres. At 90km/h it would take a car something between 20 to 25 seconds to cover that distance – not 2 seconds. Further this witness gave clear evidence that “probably 30 seconds or something” after hearing the crash, she observed the other two vehicles approaching from Brighton. The only inference I can draw is that these two vehicles were either N32 and Mr. Millar or alternatively N33 and N32
I will deal now with some relevant aspects of the evidence surrounding the police following or attempting to intercept Billy’s vehicle. In doing so I will note some discrepancies in that evidence to note that I have taken them into account in my findings.
It is important to observe that all 3 police officers involved in attempting an intercept believed the speed limit on Baskerville Road to be 80km/h whereas it was really 100km/h.
It is the evidence of the Constables Francombe and Deutschbein that Billy’s vehicle was accelerating away from them at speed and they caught sight of it from time to time around corners or on crests. Sgt Semmens in N32 observed one set of headlights proceeding at high speed towards him. He stopped N32 420 meters north of the crash scene and on a straight section of road. He flashed his high-beam lights at the oncoming vehicle and estimated its speed in excess of 120km/h when it passed him, flicking up material from the verge on the side of the road. He estimated that N33 followed approx 500 to 600 meters behind and at about 90km/h. His evidence is that he did not observe Mr. Millar’s motor vehicle at all until it arrived at the crash scene after N32.
It is the evidence of Constable Francombe, in his first affidavit sworn on the 11 June some 18 days after the crash, that “at the same time I began driving in the same direction as the vehicle with the intent to intercept it or to determine its intended destination. I accelerated down the hill to the speed limit of Baskerville Road, about 80mk/h. By the time I had began accelerating, the vehicle was already negotiating the next bend after the downhill straight. I estimate the vehicle’s speed in excess of 100km/h. When I negotiated the first bend after the straight I estimate my speed to be about 90-100km/h. The vehicle still appeared to be accelerating heavily and judging by the distance he had gained from me, I estimate it was now doing about 120km/h………After observing the vehicles driving behaviour I conducted a risk assessment. I have driven Baskerville Road many times prior to the incident and as I estimated the vehicle’s speed to be excessive, I assessed it was not safe to travel as fast as the other vehicle so therefore maintained speeds close to the Baskerville speed limit”.
It must be observed that Constable Francombe made a third affidavit on the 2 August 2010, some 10 weeks after the crash and some inconsistencies arise in relation to when he assessed the risks of continued pursuit.
In that affidavit he stated – “When the deceased’s vehicle initially drove off on Baskerville Road, I immediately began a risk assessment taking into factors of the road conditions, the deceased’s driving behaviour and our intended course of action. I am aware of the Tasmania Police pursuit policy including the definition of pursuit. At the moment when the deceased drove off, I established that the deceased had not committed or attempted to commit a serious crime as defined in Appendix B of the Criminal Code Act. I therefore did not initiate a pursuit and did not activate my emergency lights or sirens. I believed the deceased had already showed the intention of failing to stop for police and did not consider an attempt to intercept the vehicle during the time before the crash. Although the deceased was driving in an erratic manner, I didn’t consider any other persons to be in immediate danger which also supplemented my reasons for not attempting an intercept or pursuit. I maintained observations of the vehicle from a distance and intended to make a further risk assessment once further information became available regarding the intended destination of the vehicle……..I was not driving at high speed and believe my manner of driving did not warrant the use of emergency lights or sirens.”
There is also some inconsistency with Constable Frankcombe in the evidence of Senior Constable Deutschbein about the intentions and decisions about pursuit.
It is the evidence of S/C Deutschbein that N33 did not follow at speed. In his first affidavit of 11 June 2010 he made no reference to any risk assessments although he did say that Billy’s vehicle “was obviously going over the speed limit and was distancing itself from our vehicle”. “We slowed further and passed Sgt Semmens….. the vehicle had made a lot of distance from us by that point.” He gave no evidence of the speed of N33 or any comment about pursuit and made no comment about any discussions or decisions about pursuit, he gave no evidence as to whether emergency lights were activated or not, although he did say that when they pulled up behind Billy’s car outside 570 Baskerville Road that the emergency lights were not activated and that when they arrived at the crash site “we engaged the emergency lights to alert any passing traffic of the obvious danger and pulled over on the side of the road”.
However, in his third and supplementary affidavit of evidence also made on the 2 August 2010, he deposed in somewhat similar terms to Constable Frankcombe that they had had a discussion during their driving after Billy’s car and that “during the drive I had a discussion with Constable Jonathon Frankcombe regarding our response to this incident. We discussed the pursuit policy and as no Appendix B crime had been committed and there did not appear to be any danger to any persons at the time we agreed we were making the correct decision to not engage in the pursuit of the vehicle. Road conditions were also discussed. I mentioned that the road has some tight bends and crests and agreed that we should not engage lights or drive in a manner justifying the use of emergency lights”.
Notwithstanding these concerns I cannot say that I should not accept the evidence of these two police officers. There is no direct or indirect evidence to the contrary.
It is the evidence of Sgt Semmens that he observed Billy’s vehicle approaching him at high speed. He stopped N32 on the left part of the straight section of road and “as the Commodore approached me I flashed it twice with high beam headlights. My intention was to make the oncoming driver aware of my presence and also to provide me with a brief opportunity to identify the occupants….. as the vehicle passed it flicked up material from the verge of the road…… I estimate the speed of the oncoming vehicle to be in the order of 120km/h…… I then observed the police vehicle occupied by Constables Deutschbein and Frankcombe approach from over the bridge and pass me. I would estimate the speed of their vehicle at 90km/h. The emergency lights were not activated. I estimated a separation of 500 to 600 meters”. Sgt Semmens then traveled north for a further 200 meters to execute a u-turn and followed N33.
I have considered the probability of the flashing of the high-beam lights at Billy’s oncoming vehicle at high speed, at night and on a narrow road, may have dazzled Billy or impaired his vision to such an extent he lost control and the crash was caused. While I cannot rule out that it may have contributed to Billy’s subsequent loss of driving control, there is the uncontradicted evidence that this occurred some 420 meters or more from the crash site and at 120kmh it would have taken the Commodore some 12 to 13 seconds to cover that distance. On that basis it is less likely it was a direct cause of or contributed to the crash. I note that Tasmania Police intended to counsel Sgt Semmens about the general dangers of flashing high beams at oncoming vehicles especially in the circumstances similar to this case. I endorse and recommend that counseling, not only of Sgt Semmens but to all police officers.
It is the evidence of Mr. Millar that when he observed the Commodore drive off at speed followed by N33 – “The police car had its lights flashing, meaning the red and blue lights, but I did not hear a siren.”
He went on to say that he followed and about 1km further on he came up behind a police vehicle traveling at 70km/h and with no emergency lights activated. He said “it was definitely the same one I had just seen….further ahead I noticed the tail lights of the white Commodore, it appeared to be speeding on a straight section of Baskerville road, it was approximately 300 – 400 ahead of me”. It was dark, Mr. Millar was some distance from 570 Baskerville Road and followed at only 50 -55kmh for the first 500 meters before accelerating and then accelerated to the 80kmh speed limit. He had no prior knowledge of the presence of N32 on the road.
The two police officers have denied that the red and blue emergency lights were activated in N33 at any time prior to any subsequent crash.
I am unable to resolve this discrepancy in the evidence, one way or the other.
What is clear is that there was no permission neither sought nor given for the officers to activate those lights at that time.
Mr. Millar says that after he came up behind the police vehicle he followed it, 2 to 3 car lengths behind at about 70km/h. At no time did any of the three police officers observe Mr. Millar’s vehicle or were aware it was following any police vehicle before it arrived at the scene of the crash. It is their evidence they would have observed Mr. Millar’s vehicle had it been behind any of them.
I am unable to make any specific findings about the discrepancies in this evidence although it is reasonable to infer the police vehicle ahead of Mr. Millar was possibly N32. It is possible that Mr. Millar may be somewhat mistaken about the identity of the police vehicle and may well have come up behind N32 after it had executed its U turn in front of him and he followed it to the crash site.
Upon all of the available evidence it is clear that outside 570 Baskerville Road and for a distance I cannot accurately determine but somewhere in the region of 500 metres police did make an unsuccessful attempt to intercept Billy’s vehicle and in some degree were in pursuit of it. I am unable to make any finding as to whether N33 had activated its emergency lights for any period of time or at all. However, in all of the circumstances it must have been clear to Billy, at least for those 500 metres or so, that police were pursuing or may well do so. His high speed response to the presence of police especially after his earlier interaction, albeit at a distance, with Mr. Millar, would indicate he was aware of the presence of police. He was not properly licenced to drive and that coupled with the clandestine nature of his meeting with Kaitlin and his nervousness as to what his parents might think or do if they found out, may well have prompted his high speed departure when approached and his intent to evade police.
Even if N33 had its emergency lights activated for a period and no permission was sought by the PO to activate such lights, I cannot say that such action or lack thereof caused or contributed to Billy’s crash. On all available evidence he drove at high speeds estimated in excess of 120km/h and significantly faster than N33 and well in excess of the speed limit and in my view too fast for the road conditions on Baskerville Road and too fast for his level of driving experience. Further, he failed to stop or slow down upon the flashed lights of N32. It is clear he deliberately drove off from police and his manner of driving thereafter displayed an intention to evade police.
While N33 may have reached speeds of 90 to 100km/h these speeds did not exceed the posted speed limit, despite all police officers mistakenly believing that the limit was 80km/h. It is clear that the gap between N33 and Billy’s car was widening during the relevant journey and to the extent of 500 to 600 metres gap at about the time of the crash – {in a report completed by Sgt Semmens at the conclusion of duty on 25 May, he reported that ‘the accident was not observed by police due to the large distance of separation”. }
Notwithstanding these circumstances, Billy did not slow down or desist from his high speed driving.
In all of the circumstances I find that there was no ‘pursuit’ as defined in police policy. There was an initial attempt to detain Billy Grice but, upon the police officers in N33 desisting in the pursuit I am of the view it is not clear that they were attempting to detain Billy to the extent that I can say that section 24(1) (e) is applicable and to the extent that at the time of the crash police were attempting to detain him.
Nevertheless the exhaustive police investigation identified that had Constable’s Frankcombe and Deutschbein not been in error about the posted speed limit, that is had it been 80kmh rather than 100km/h, then they would have been in breach of the TPM pursuit policy. I agree with the views of Inspector Fogarty that the evidence suggests that while the Constables were aware of the pursuit policy, they did not posses a sufficient level of knowledge and understanding of it. On their evidence they would have exceeded the speed limit in circumstances not related to an emergency involving obvious and immediate danger to human life or the detection of a serious crime.
Further, the investigation highlighted concerns and/or breaches of TPM procedures or failures to follow instructions, for example –
- Failure to notify RDS of their status and location on their arrival at 570 Baskerville Road,
- Failure to appropriately update RDS as they were following after the vehicle, - especially that the vehicle was travelling at 120km/h and that a risk assessment had been conducted including taking into account road conditions,
- Failure to appropriately advise RDS of the nature of the driving behaviour observed,
- Failing to keep supervisors appraised of events probably lead to the failure of a duty Inspector or Divisional Inspector to attend the crash site to ensure prompt coordination of emergency services, the attendance of forensics, accident investigation services and in the circumstances of the case, the attendance of Police Internal Investigations unit,
- The initial failure to assess the crash scene as a ‘serious accident’ scene.
While none of these events or failures caused or contributed to Billy’s death and did not affect the medical treatment provided for him and did not apparently significantly impact upon the police/crash investigation; the proper adherence to protocols and procedures may well have importantly assisted the evidence gathering for the coronial inquiry.
Errors of judgment were made possibly brought about by inexperience and the suddenness of the events, and again I adopt and endorse the recommendations of Inspector Fogarty that the police officers involved in this case and any other police officers likely to be involved in similar but hopefully infrequent events, should have further training and awareness of operational and supervisory issues highlighted by this case.
These failures contributed to RDS operators and supervisors failing to fully appreciate what had actually occurred and from a Coroners’ perspective the available evidence for the inquiry, the following of those protocols may well have assisted the investigation by making plausible corroborative evidence available from the outset.
I accept that police officers are placed in an invidious position when it comes to a decision whether it is in the community interest to pursue or not a person suspected of a crime or likely to become involved in a crime including minor traffic breaches which may escalate into more serious driving events and consequences. It is almost a situation of ‘being damned if they do or damned if they do not’. Initial detailed training in and constant review of the published policies and protocols and adherence to them will obviously assist them in that decision making process. I am informed and accept that Tasmania Police will invoke its own internal actions in relation to the two police officers for having breached procedures and have no doubt that it will adopt my recommendations into continuing training in the implementation and compliance with existing policies/procedures and protocols relating to these or similar circumstances.
Baskerville Road is a relatively narrow road and has numerous curves, bends, crests and dips. Evidence from the Roads and Traffic Division of the Department of Infrastructure, Energy and Resources shows that between 1 January 2005 and 21 June 2010 there were two other reported crashes within 1 kilometre on either side of the subject crash, all involving loss of control on a bend. It conducted an assessment of the road and noted that ‘winding road next 6km’ warning signs are provided at both ends of the road, but recommended that the Brighton Council relocate the curve warning signs and 45km/h advisory speed signs for southbound traffic (in the vicinity of the crash) further away from the curve, to make them more visible to southbound drivers. It is not likely that speed limits were a critical factor in this crash, but I also note that the Manager of Traffic Safety was consulting with that Council regarding the installation of a 70km/h speed limit for that entire section of road. I make no recommendation about that as there are no doubt many other factors to take into account, but it is important that the issue has been properly considered.
Findings and Comments :
I find there are no suspicious circumstances in and about the tragic death of Billy Grice. I find that a swollen brain with closed head injuries with consequential pneumonia was the cause of death. I also find those injuries occurred in a motor vehicle crash on 24 May 2010, on Baskerville Road.
It is quite probable Billy drove away from police at high speed in a state of inexperienced panic and concern at being confronted by a police officer. Whatever his reasons, it is clear his actions were entirely uncharacteristic for this young man and I offer my most sincere condolences to his family and friends for their tragic loss.
Dated 5 October 2011 at Hobart in the State of Tasmania.