Record of Investigation Into Death (With Inquest)

Corners Act 1995
Coroners Rules 2006
Rule 11

I, Simon Cooper, Coroner, having investigated the death of Noel Alan PERCY.

WITH AN INQUEST HELD AT the Coroners Court, Hobart in Tasmania on 28 and 29 April 2014


1.   Noel Alan Percy was found hanging in his cell at Her Majesty’s Prison, Risdon (‘HMP’) at about 11:30am on 6 May 2012. At the time of his death he was detained as a remandee and housed in Cell 3 of the Rowallan Charlie Unit, HMP, and awaiting trial upon a charge of murder as well as some serious drug matters. Section 24(1)(b) of the Coroners Act 1995 (the ‘Act’) requires a coroner who has jurisdiction to investigate a death to hold an inquest into such a death occurring in such circumstances.

Formal Findings:

2.   In every case the subject of a coronial investigation section 28 of the Act requires a coroner to make, if possible, various findings. In that regard the evidence at the inquest satisfied me that:

a) The identity of the deceased person was Noel Alan Percy;
b) Mr Percy died in the circumstances set out in this finding;
c) Mr Percy died as a consequence of asphyxia caused by self-inflicted hanging;
d) Mr Percy died at HMP, Risdon in Tasmania on 6 May 2012;
e) Mr Percy was born on 26 October 1971 in Hobart, was at the time of his death an inmate of HMP, and on remand in relation to, inter alia, a charge of murder, was married and in custody; and
f) No person contributed to the cause of his death. 

3.   In making the finding that I have with respect to the cause of Mr Percy’s death, I expressly accept the opinion of Dr Donald Ritchey, Forensic Pathologist. I will expand upon his evidence later in these reasons. Similarly, the reasons why I am satisfied no other person contributed to Mr Percy’s death as well as the other formal findings will be discussed later in this finding.

Mr Percy's Background:

 4.   The evidence at the inquest, none of which was in dispute, and which therefore requires no findings of credit or reliability to be made, shows that until 2005 Mr Percy seems to have led a productive and relatively unremarkable life. He was born and raised in southern Tasmania and attended schools in the south of the State. He had a good work history with various employers such as the Blundstone boot factory in Moonah, EZ in Lutana, and for a number of years at the Devil Jet Boat which operated at New Norfolk.

5.   Mr Percy married Shelly Percy on 29 August 1992 and shortly after their marriage they moved to Bagdad. He fathered three children: Michael, Brittney and Porsha. The evidence at inquest suggests that Mr Percy enjoyed a normal family life and that he was a loving husband and father.

6.   All this seems to have changed after AFL Grand Final day in September 2005. On that day Mr Percy was run over by a motor vehicle, after he had consumed a significant amount of alcohol, and suffered serious injuries as a result. Those injuries included frontal lobe damage and injuries to his spine. Family members, including his mother Mrs Ann Percy, report that after that day he was “never the same”. His wife reports that following the accident he suffered mood swings and became verbally aggressive. On at least one occasion he was physically violent towards her. In addition he became reclusive, refusing to visit other family members or attend normal family functions, behaviour which was markedly different to that he displayed prior to being run over.

7.   Evidence tendered at the inquest reveals that during an evening sometime in 2009, Mr Percy introduced his wife to Anna-Lyce Olding (born 21 December 1986). Mr Percy told his wife that Ms Olding was a friend and encouraged his wife to befriend her. This Mrs Shelly Percy did. Just before Christmas 2010 Mr Percy told his wife that Ms Olding was in fact his daughter. His wife accepted this and Ms Olding’s son, Alexander O’Malley, apparently even commenced calling Mrs Shelly Percy “Nan”.

8.   Before the introduction of Ms Olding, Mrs Shelly Percy reports significant changes in Mr Percy’s behaviour. He was apparently hardly ever home and he seemed to be spending a substantial amount of time with a friend (or acquaintance) Brendan Marriott.

9.   The evidence at the inquest was that Mr Percy and Mr Marriott were involved in the production and distribution of methamphetamine. Mr Percy was the person responsible for the production of the drug (or ‘cook’ as it is apparently know in such circles).

10.   It is unnecessary to canvass in much detail the circumstances of the murder charge against Mr Percy with respect to Brendan Marriott’s death. I note that Coroner Rod Chandler concluded in a finding in March this year that Mr Percy was responsible for Mr Marriott’s death on or about 2 December 2010 and, along with others, responsible for the burning and disposal of Marriott’s body.

11.   However to place Mr Percy’s death in context some background needs to be set out. On 28 March 2011, Mr Percy, his wife and three children were at their home at Bagdad when police arrived and arrested Mr and Mrs Percy. Mrs Percy was detained in the Hobart Reception Prison (‘HRP’) overnight but released the next morning (after being charged). Mr Percy was arrested and detained in HRP and then transferred to HMP having been charged with the murder of Brendan Marriott and some serious drug offences.

12.  Whilst in police custody Mrs Percy became aware for the first time that Ms Olding was not Mr Percy’s daughter, but rather his mistress.

13.  For the purpose of this investigation it is sufficient to say that I find that Mr Percy shot and killed Mr Marriott and that Mr Percy was charged with that murder and lawfully detained in custody pending his trial on that charge.

14.  Mr Percy entered the Tasmanian prison system (for the first time in his life) on 29 March 2011. As has already been noted he was placed initially at the HRP. Upon his entry into custody the evidence discloses that he was the subject of a “Tier 1 assessment”. A Tier 1 assessment is conducted when any person enters the prison system. It is designed to elicit personal information, determine the appropriate security rating applicable to that person, identify potential housing options (that is to say, whether in the HRP or the main prison complex itself), and determine the health and well-being of that person.

15.  Because Mr Percy was on remand for, inter alia, murder, he was assessed as having a security classification of “maximum”. This led to a decision being made to house him within the maximum security precinct of the main prison complex at Risdon.

16.  During the Tier 1 assessment Mr Percy revealed to staff at the Hobart Reception Prison the details of the injuries he sustained in September 2005. Recorded also as part of that assessment was the fact that Mr Percy disclosed to prison staff that he had recently considered self-harm or suicide. As a consequence of this disclosure prison staff classified Mr Percy as risk level “3/3”. This classification meant that Mr Percy was subject to very regular monitoring as a consequence of his self-harm ideation, the fact that he was on remand for very serious crimes (indeed the most serious crime), and because it was his first time in the prison system.

17.  Prison Service Custodial Staff sought advice from nurses at the Hobart Reception Prison and as a consequence of that advice it was recommended that Mr Percy be sent to, and housed in, the Crisis Support Unit (‘CSU’) within the main Risdon Prison complex. The purpose of him being housed in the CSU was to enable a mental health assessment to be carried out.

18.  The next day, 30 March 2011, Mr Percy was transferred from HRP to HMP. He was initially housed within the Mersey Unit, which is a special unit for high need inmates such as those considered at risk of self-harm or suicide. Whilst housed in the Mersey Unit he was seen on a number of occasions by a psychologist. That psychologist conducted an assessment of Mr Percy. That assessment revealed a long history of depression and treatment and support from both a psychiatrist and a psychologist. Mr Percy also revealed during that assessment that he was prescribed anti-depressant medication.

19.  As a consequence of, and subsequent to, the assessment conducted by the psychologist referred to immediately above Mr Percy was admitted to the prison “needs assessment unit” to enable observation of him and to allow him to commence supportive counselling. During this time Mr Percy’s risk assessment rating remained at level three. He was reviewed on 1, 5 and 6 April. Following his review on 6 April Mr Percy was released into main stream accommodation within the prison. Initially he was housed in the Derwent Bravo Unit of the maximum security section of HMP. Whilst housed in that area of the prison Mr Percy was subject to further regular reviews. His whole prison file was tendered at the inquest. That file reveals uniformly positive case note entries in relation to his conduct and behaviour.

20.  He was assaulted by another prisoner on 31 May 2011 but sustained no significant injuries and chose not to pursue any action against his attacker. Once again his prison file reveals that he was noted by prison staff to have behaved excellently during this incident.

21.  He was reviewed again by the senior prison psychologist the next day. Mr Percy reported no psychological concerns as a consequence of the assault but indicated that if he considered he needed support he would request it.

22.  During this month his prison file reveals that he was recommended to progress to “contract level 4” as a consequence of his continued good behaviour in prison. This recommendation was accepted by prison management and as a result he was transferred from maximum to medium security. With the transfer to medium security came a transfer to the Rowallan Charlie Unit where he remained housed until his death.

23.  Whilst housed in the medium division Mr Percy commenced some educational programs. This included studying at a tertiary level. He also undertook trade training in relation to laundry operations.

24.  His file reveals that he was uniformly regarded as being a “model” prisoner. Notes described him as “cheerful”, “polite” and “quite compliant”. As a result of his continued good behaviour his prisoner behaviour rating increased to “contract 4 +”. The evidence at the inquest was that this rating is awarded to only the very best behaved prisoners within the prison system in this State. The unit in which he was housed, Rowallan Charlie, is reserved for the best-behaved inmates within medium division.

25.  His file reveals that he did seek a transfer to the Hayes Prison Farm but this was rejected by prison management due to the fact that he was still on remand for murder.

26.  An examination of his file indicates that prison correctional and medical staff members were in regular contact with Mr Percy and that their assessment of him was uniformly positive.

27.  Whilst in prison Mr Percy was in regular telephone and physical contact with Ms Olding and other members of his family. In addition, he was visited on one occasion by Mrs Shelly Percy. He was also visited on a number of occasions by his mother and his youngest daughter, although the visits of Porsha reportedly caused Mr Percy a degree of distress because she was reportedly upset at the end of each visit and did not wish to leave.

28.  He was visited by Ms Olding roughly three times a week for the whole time he was in prison. In the months prior to his death prison records indicate that Mr Percy had 12 contact visits with Ms Olding.

29.  In addition to regular contact visits with Ms Olding and other members of his family Mr Percy was in regular telephone contact with Ms Olding. In the six months prior to his death Mr Percy made over 50 telephone calls to Ms Olding. Those telephone calls were, like all telephone calls made by prisoners and remandees, the subject of monitoring by the prison authorities.

Events leading up to Mr Percy's death and the death itself:

30.  On the day of his death, 6 May 2012, Mr Percy was provided with two visitor passes by a correctional officer. The visitor passes authorised visits at 9.00am and 1.15pm. Both authorised the same visitors, Ms Olding and her son Alexander, to visit Mr Percy at those times. The correctional officer who issued the passes to Mr Percy noted no issues at all with his state of mind or anything else which caused concern.

31.  The evidence discloses that Mr Percy attended the visitor centre at roughly 9.00am for his first scheduled visit. There he was, in accordance with normal procedure, strip-searched in preparation for that visit. However Ms Olding did not arrive as had been arranged, and as Mr Percy clearly expected.

32.  Mr Percy returned to the Rowallan Charlie Unit. There he spoke with another inmate, Mr McIntosh, whose evidence was that Mr Percy appeared upset and said to Mr McIntosh words to the effect of “bloody women … I’m not going to put up with her”.

33.  Mr Percy spoke by telephone to Ms Olding at 9.32am on the day of his death. This was after Ms Olding failed to attend for the pre-arranged visit on the same morning. That telephone conversation was recorded by the ‘Arunta Telephone Monitoring System’ in use within all Tasmanian correctional facilities. The conversation lasted one minute and 47 seconds. In the conversation Mr Percy asked Ms Olding whether a particular man was present with her – something she denied. The tenor of the conversation suggests clear concern on Mr Percy’s part about his relationship with Ms Olding. The conversation ended abruptly when Ms Olding went to separate two dogs fighting. It was the last occasion Mr Percy and Ms Olding ever spoke.

34.  For her part Ms Olding explained in evidence that in the two weeks prior to Mr Percy’s death she had become ‘close’ to another man, a tattooist in Risdon Vale where she ‘got her piercings done’. Mr Percy knew about this relationship although she had re-assured him that it was only a friendship. Apparently Mr Percy was jealous of Ms Olding’s friendship with the man.

35.  There is little doubt that in this telephone conversation Mr Percy evinces a real concern about his relationship with Ms Olding and her fidelity to him.

36.  Shortly after the conversation, at around 10.00am, Mr Percy attended the education building of HMP, where he received a haircut from another inmate. During the haircut Mr Percy and the inmate barber arranged to have coffee and cigarettes later that morning.

37.  After the haircut Mr Percy returned to the Rowallan Charlie Unit. At about 11.00am an inmate Mr McIntosh reports that Mr Percy locked himself in his cell. In accordance with usual routine and procedure he left his keys on the outside of his cell door along with his identification. Shortly after this Mr McIntosh and another inmate Mr Aliano described hearing what they believed was Mr Percy manipulating his internal door lock. Both considered this to be unusual behaviour. Mr Aliano approached the door and spoke to Mr Percy asking him if he had a cigarette but received no reply. Not unreasonably Mr Aliano and Mr McIntosh formed the view that Mr Percy wanted to be left alone and as a result let him be in his cell.

38.  At around 11.30am correctional officers commenced lock down and a muster of the prisoners in anticipation of lunch. The usual procedure was (and followed on this occasion) that the prisoners were provided with their lunches and then placed in their cells when the muster was carried out. During this process Correctional Officer Frost commenced the muster in Rowallan Charlie Unit and Mr Percy failed to present as required. Two inmates approached Mr Percy’s cell door. They attempted to raise him but without success. As a consequence three correctional officers entered the Rowallan Charlie common area and attempted to gain entry to the cell. The door to the cell was overridden and able to be opened slightly.  Correctional Officer Mundy was able to look inside the cell where he saw Mr Percy in a seated position with his back against the cell door. Entry was then immediately gained. Correctional Officer Mundy noted Mr Percy was not breathing, his lips were blue, and a white shoe lace was suspended around his neck. He also saw a ligature mark on Mr Percy’s neck.

39.  In an entirely appropriate response correctional officers placed Mr Percy onto his back and immediately commenced CPR. A so-called “Code Blue” (a medical emergency) was called and prison nursing staff immediately attended and an ambulance was called. Whilst this was going on, other correctional officers removed the remaining inmates from the unit. All of this was captured on CCTV which was tendered in evidence at the inquest.

40.  Shortly after the Code Blue was called prison nursing staff arrived and connected a defibrillator to Mr Percy. The machine indicated “no shock given, continue CPR”. The CPR was duly continued by correctional officers and nursing staff on rotation until the arrival of Tasmanian Ambulance Service paramedics.

41.  I am well satisfied that the responses of all the correctional officers, and in particular Officers Frost and Mundy, were appropriate. The treatment afforded by the correctional officers to Mr Percy by way of CPR, including the use of the defibrillator, was also entirely appropriate. Nothing more could, in my assessment, have been done for Mr Percy.

42.  Upon arrival, paramedics from the Tasmanian Ambulance Service directed that Mr Percy be moved from his cell into the common room to enable further medical treatment to be undertaken. In total it is clear from the CCTV footage as well as other material that CPR was continued for around 45 minutes before the ambulance officers formed the view, at around 12.18pm, that treatment was futile as Mr Percy was clearly dead.

43.  The scene was secured and sealed with tamper evident tape. The whole complex was also secured. Police officers arrived and were briefed. Members of the Criminal Investigation Branch and Forensic Services were tasked to attend. The Coroner, Coroner’s Associate and a Forensic Pathologist were all notified and all attended the scene.

44.  After Mr Percy’s body was examined at the scene it was transported to the Royal Hobart Hospital by mortuary ambulance where it was identified.

45.  The circumstances surrounding Mr Percy’s death were extensively investigated. That investigation included carrying out of an autopsy at the direction of the Coroner. The autopsy was carried out by Dr Ritchey.  Dr Ritchey expressed the view in evidence before the inquest, which view I accept, that Mr Percy’s death was due to asphyxia caused by self-inflicted hanging. Importantly, Dr Ritchey explained there were no injuries to Mr Percy’s hands or fingers and nothing in the nature of defensive injuries. The only injury to his body was a single narrow deeply furrowed ligature abrasion across the neck above the thyroid prominence. In short his conclusion was there was no evidence whatsoever of the involvement of any other person in Mr Percy’s death. In addition the evidence of other inmates as well as Correctional Officers and the CCTV footage all lead to a conclusion it was impossible for any other person to have been involved in Mr Percy’s death.

Report on care and supervision of Mr Percy whilst in custody:

46.  Section 28(5) of the Coroners Act 1995 is in the following terms:

“(5) If a coroner holds an inquest into the death of a person who died whilst that person was a person held in custody or a person held in care or whilst that person was escaping or attempting to escape from prison, a secure mental health unit, a detention centre or police custody, the coroner must report on the care, supervision or treatment of that person while that person was a person held in custody or a person held in care.”

47.  I am affirmatively satisfied on the basis of the evidence at the inquest that the care and supervision of Mr Percy was of an entirely acceptable standard and in no way caused or contributed to his decision to take his own life.

48.  I should say that although Mr Percy was housed in a cell which had a hanging point, on no reasonable review of the circumstances could the decision to house him in that cell be considered inappropriate.

49.  I am well satisfied that the individual responses of the correctional officers involved in dealing with Mr Percy’s hanging were also appropriate. I am also well satisfied that the systems in place to deal with all prisoners, but in particular Mr Percy, were appropriate and in no way caused or contributed to his death.

Comments and Recommendations:

50.  The circumstances of Mr Percy’s death, and the conclusions I have reached as to the circumstances surrounding it, do not require me to make any further comment (other than that as set out above) nor do I make any recommendations.

51.  I express my appreciation to the principal investigating officer, Constable Lovell, and First-Class Constable Kerr, who acted as counsel assisting at the inquest, for their assistance and professionalism.

52.  Before I conclude this matter, I wish to convey my sincere condolences to the family of Mr Percy.

DATED:  19 August 2014 at Hobart in the State of Tasmania

Simon Cooper