The public has had a long held fascination with detectives.

Detective see aside of life.

The average person is never exposed her I spent thirty four years as a cop.

For twenty five of those years, I was catching killers.

That's what I did for a living.

I was a homicide detective.

I'm no longer just interviewing bad guys.

Instead, I'm taking the public into the world in which I operated.

The guests I talk to each week have amazing stories from all sides of the law.

The interviews are raw and honest, just like the people I talk to.

Some of the content and language might be confronting.

That's because no one who comes into contact with crime is left unchanged.

Join me now as I take you into this world.

In part two of my chat with former Deputy State Coroner Hugh Dylon, we talk about some of the cases you oversaw in his nine years as a deputy state coroner.

We talk about murders, about suicides, missing persons, and even critical incidents that's where someone has died as a result of a police operation or in custody.

But probably the most important thing we talk about is how we can improve the coronial system.

We're lucky to have someone who's experiences Hugh Dylan to talk about such an important role.

Hew, welcome back to our catch Killers.

Thank you Gary.

It's great sitting down talking to you.

In saying that, it just makes me reflect on all the things that you see and do in the career that you've had.

In the amount of times I've been in the Coroner's court.

One of the things about the Coroner's court I did most of my career in Glebe Currenter's Court, or even now that at Westmead, I'm glad the courts have finally upgraded.

Yeah it's a pretty spick and span new building.

Yeah, I'm not quite sure the system is, but maybe we'll get all.

We're going to talk about the system, because I'm always in a grants something could be improved, and especially something as important as the coeronial process, we should at the very least talk about it.

So we'll definitely cover off on that.

But I remember with the Globe Coronis Court because quite often there's people that there's the families of the victims and there's also people that the family suspected being involved, and there was a very small meeting point and from a police officer's point of view, trying to keep the parties apart was near impossible in that environment.

Yeah, I imagine.

So I fortunately didn't have to deal with that myself, but I was aware.

I was constantly aware of the potential for clashes or even for the need for security on occasions, fortunately not very many.

Yeah, but yeah, that could be very tense meeting places.

It was a very confined environment.

It made it difficult.

One case I want to talk to you about, and I want to talk in general about critical incidence, But just as a point of reference, was the death of Ryan Pringle as a result of a police shooting.

Now.

I think that was in twenty twelve.

It was up in Tenterfield.

I was a senior investigating officer for that, for the Critical Incident Team.

I was working in homicide and got called out I think it was a Sunday night, and flown up to ten to fill the circumstances in which that occurred.

You and I have spoken about it, because you ever saw the inquest into the matter.

It was quite horrific, wasn't it.

It's extraordinary.

That was a truly nightmarriash case.

Usually when police are involved in some sort of scenario and someone dies, they've come on a scene where someone's threatening others and so forth.

In this case, mister Pringle was actually hunting the police themselves, which was well put me a mind of the film Deliverance.

You say Deliverance, And it was a horrendous situation.

As I said, I got called out on a Sunday night flowing up there what happened in this particular situation that was at a farm that was called the School of Happiness, which was a type of a hippie gathering if you would probably a way of describing it.

There for a festival, and they were camping down near a river, so there was a lot of vans and different things and buses down there a river, and Ryan had been involved in a confrontation with some of the members at this festival.

Police have been called and that it's public record.

I mentioned their names, Karen Peasley and Carter that Knivett were called out and they were actually married, their husband and wife team.

They've gone out to this location and there's no communication.

So we're looking at Tenterfield, the town.

It was about an hour's drive out from there, in a very remote location with no communication.

Not just a police radio telephones.

There was black spots all over the place.

They get out there and Ryan's decided to start stalking them.

The police I thought were very brave in that they went and gathered up all the people at the festival and got them all to travel out.

Was like a wagon train, getting getting everyone to pack up their gear and getting their vans and follow the police car.

Just as they're about to move off, and this is in late at night and the pitch black there, Ryan's come out of the shadows and calling out the police and threatening to kill them, and it ended up in a chase round a van and taser was deployed and then eventually Ryan was shot before and he had a laded cross aimed at the police.

Absolutely horrendous circumstances.

I compiled the brief of evidence and provided to you as a coroner.

What's your takeaway from a situation like that?

Because no one wins, a person's lost their life, but the people have been terrified by witnessing what had occurred.

What's your takeaway from an incident like that?

Well, I think there are a number of takeaways.

The first The first thing is, obviously your life has been lost, and in this particular case, there were tragic elements of it.

Ryan lost his life because he threatened the police and they acted in self defense.

But whether he was mentally sound or not, you'd have to you'd have to doubt it'd been dabbling in drugs and so on and so forth, and so that said something sad about his life.

I think his father I remember being very affected by Ryan's death, but not angry so much as sad, and I felt really sorry for him, and of course for the extended Prinkle family.

The Prinkle family has to live with Ryan's death.

But unusually, the police here were almost victims themselves, and I can't imagine how terrifying that must have been, to be honest, to have someone hunting you with a crossbow, as you said, pitch darkness, armed only with tortures and so forth, and the torch, of course, could show show Ryan where you were as much as possibly illuminate him.

So an incredibly frightening situation.

And then the police were trying to protect a whole gaggle of people who were simply there for a good weekend and so forth.

They were ordinary country police, you know, just decent people trying to protect members of their community and suddenly they're being hunted for their lives.

Well, the way you describe it them referencing the movie Deliverance had that feel about it because they were being hunted and he was calling out, addressing camouflage gear, making threats against them, asking all the other people to join in and kill the police.

It was something that was surreal, and I remember part of my role as a critical incident investigator that I had to interview the police involved, and I thought that very professional, but it was traumatic listening to them recount what had happened, and at no point they could shine their torch, but then they'd have to turn their torch off because if they're shining their torch trying to see in the dark where he was coming from, they potentially made themselves targets exactly, and they did everything they could to avoid the confrontation and all the warnings and literally running around the van with him chasing them.

It was just a horrendous situation.

And then add to it, and I think it gave me a lot of respect for what country cops do, Like there weren't there wasn't any backup for them, the communications.

It was an hour or two before other police came by.

You've got the other people in the situation.

Someone's just been shot and critical injuries and they're left there dealing with that.

I think Carter told me he wasn't sure if the rest of the community were going to attack him after the shot, and he thought that might be so just a horrendous situation.

Very horrendous and very courageous of them.

Yeah.

Well, one of the recommendations that came out of the inquest was that they'd be awarded some sort of gallantry metal accommendation, which I think they received later on.

Yeah, they did.

Know.

I've seen a lot of things in policing, and that was one that was right up there because they didn't have to stay.

They could have just driven out, but they were protecting the public in classic what police should be doing, and putting their own own situation at risk and doing that.

There was in all the darkness you do see some humor, and the people that you would expected a gathering of the Moon Festival or whatever on the School of Happiness Farm were an eclectic group of people.

There was one I can say this, I don't think he'd take any offense.

I think he'd be proud of it.

There was one particular person that was a witness to this situation that he didn't believe in wearing clothes.

Clothes just weren't his scene.

And I don't think you realize, as the deputy state coroner how much work we had to go do behind the scenes to get that witness to appear in court with some clothes on.

I didn't know that.

We explained that, you know, it's probably a situation where you should wear your clothes, but I don't believe in clothes.

Man, not my scene.

I think we convinced him that we're a pair of shorts and a singlet.

That's as close as we could get him.

But he was itching because he just didn't like clothes.

And I think there was another witness.

I don't think it was that one that when he was being sworn in, and I'm not saying this verbatim, but it was pretty much along the lines of what is your what could you please tell us your name?

I don't have a name, I'm an entity, and then produced a piece of paper from his pocket and produced that.

And you handle it very well as a coroner.

I knew I was dealing with some interesting characters.

Yes, well, and the hippie bus.

We had to find a place that he could park the hippie bus that wouldn't be stolen.

There was all sorts of behind the scenes work that you just don't understand on that and we're laughing about as a tragic situation.

But something that when we talk about the emotion of a matter like that is Ryan's father acknowledging the police, not blaming the police.

And I thought that was that was a really moving moving part.

Yeah, he was.

He was very gracious and very stoical.

Clearly quite a well known person because he was a well known footballer and it must have been a tremendous blow to him to lose his son, but also some degree of humiliation, I think, Yet he was.

I thought it was quite noble, really he was.

I stayed in contact with him and had a few communications with him, and he was very pragmatic about it.

He was suffering from the loss of his son, but he understood the situation that it was probably inevitable what that was going to be the end result with how his son's actions were.

But yeah, it was a strange one, but they're the type of things and I want to speak to about critical incidents because people don't fully understand the role of the coroner in a critical incident.

Critical incidence, when we refer to that in policing, is where during the police operation someone's lost their life, and that might be a police shooting or a car chase.

Critical incidents are set up as a homicide detective.

If someone's been shot by police, there'll be a homicide inspector heading up the investigation.

Then we have to present the matter to the coroner.

There are always cantentious issues.

What's your thoughts on the way critical incidence are handled well?

One large I thought they were handled pretty well.

One of the classic criticisms of it is that New South Bale's police are investigating New South Bal's police.

In some other jurisdictions you have police from other you say, police forces or whatever.

I think ideally would have independent another independent police force doing them.

But coroners are meant to be the people who provide the independent oversight and providing and I think it in practice does work pretty well because coroners are also assisted by people from the Crown Solicitor's Office, and then there's in police cases as usually a barrister from the independent bar very often a silk who is independent.

They have an ethos of independence, and some of the council assistant I've worked with have been really quite rigorous in demanding from the police investigators that they do various things, or investigate various questions, or make various inquiries.

So I think in practice that works pretty well.

But that said, there are people who, no matter how well it actually works in practice, are suspicious because it is New South Bale's police carrying out the critical incident investigation.

I know in the parliamentary inquiries in New South Bale's coroners, I think it was the Jumbunner Institute, which is an institute at University of Technology.

It's an indigenous research group made a submission that coroners were captured by police.

And there's a concept of regulatory capture that the pop you're regulating, the regulators are regulating, capture the inspectors or the regulators.

So the argument was, unless you had an independent police force doing the investigations on behalf of coroners, that the New South Wales Police Force would basically possibly potentially capture the coroners.

And so that you know the police and the coroners would think alike, that's psychologically possible, but where do you get the independent investigators.

That's I've got a got thoughts on critical incidence because a large part of my career is spent tied up on critical incidence, and I could be in the middle of a murder investigation, a critical incident would occur and that got priority.

My frustration was the amount of time I was spending on critical incidents when I'm in the throes of a homicide investigation.

But that's just from a resourcing point of view.

I think a perception is the most difficult thing to overcome.

The families and many a time I've introduced myself to the families as I'm the person ever seeing the investigation into the death of your loved one, and the initial response police investigating a police because there's anger and we're making the introductions fairly early.

There was always anger and a lack of trust.

And I've got to say, in defense of the police or my observations of the critical incidence that I've been involved in, whether I'm leading it or working on it, there is a degree of independence where that's why they bring the homicide in and part of the process.

For someone on the critical incident, you're not allowed to know the police or not to have a connection with the police involved in the incident, and that would discard you from the investigation.

So I think there is a degree of independence, but I think everyone would be better off if we did have someone else to investigate it.

And there's a lot of oversight that goes into place.

We have professional standards overside in the work that homicide are doing.

Is independent officers just a thought I always and I tried to sell this when I was in the cops.

I'm sure I'm not going to be able to sell it now, but let me try one more time.

You need the skills to investigate the death of a human.

Homicide detectives have got those skills.

I always thought the way a critical incident could be run is that homicide get called out for the first forty eight hours and make sure the crime scene is preserved, witnesses, identified, lines of inquiry, all the things set the investigation up.

Then you could bring in other people independent to come in and complete the investigation.

So homicide are basically just setting the investigation up in a direction, and then that independent body because you can't have in the state police coming in because it takes too long for them to get to the scene.

So you've got to have people be able to respond.

Homicide is set up to respond twenty four to seven at short short notice homicide there and then perhaps police from interstate or a different the investigative body because you've seen it.

I know you've seen it.

We've been speaking to people that have that view.

They won't be satisfied that police are investigating investigating police.

Yeah, that's right, and I think that's hard on the people who the police officers who do a really thorough investigation fair number of critical incident in quests, and only on a couple of occasions was I a bit doubtful about or did I have any doubts really about the quality of the investigation or the initial quality.

And by and large those problems will solved because I would have a confidence with my counsel assistant and solicitor and we'd say, okay, well, detective so and so it doesn't seem to be thinking about this or that, or maybe you know, hasn't hasn't explored this issue or something, and then we would and under the coroners Act.

You can actually direct police to do various things.

Don't like, you know, pulling rank in that way if you get cooperation.

But if you need to, you can do that.

I prefer to say it as a as a partnership.

But a couple of times, in a couple of cases anyway, council assisting said to me, I don't you know, I think we need to get the whip out and give me a bit of a tickle up or something like that.

I don't think it hurts that there's a safeguard if something's missed now, whether it's through laziness and competence.

Or just usually busy.

Yeah, well that was that.

Yeah, I started off talking about it.

My gripe was I've just been in a homicide of a critical incident that was priority because higher up the police realize that there's going to be criticisms, so we're going to say, well, we've got the people with the appropriate skills investigating when the death has occurred mental health factors that come into police students, because time and time again I saw that.

Have you got any thoughts on that?

I know on the back of the Courtney topic inquest, there was a lot of recommendations about police training for mental health.

Yeah, I've actually participated a couple of times with LEASA topic Courtney's mum in talking to police about all of those scenarios.

Incredibly difficult.

Ideally, what you'd always have if someone is psychotic in some way, you'd have a mental health team who possibly would be escorted by police, but the mental health team would be the first responders rather than police, I think.

I mean, it's very very difficult, isn't it, when police, who are very often very young, are the first responders to people acting dangerously to themselves or others.

And I've seen this happen.

I've seen police training where you know, people have shown how to back off and various techniques for trying to talk people down or keep them corraled in a safe space.

But sometimes you run out of space, and then it's and then it can be a question of basically self defense.

And I know, well, certainly I've done cases where police have shot people just too I think, and they were certainly in self defense, but they're shattering for everybody afterwards.

Well, I haven't seen a police offer so that it's been involved in a shooting incident, hasn't been affected.

It's as much bravado that can come up after shooting incident and police know I'm fine.

It does have an impact.

There is consequences.

There are consequences, and I think you know, everybody knows, everybody who's involved in these things knows that was another human being, yeah, just like me.

And they've got a family, and they see the family at the inquest.

Personally, I'd like to see lawyers who represent police officers and the Police Association try to persuade cops who involve police that turning and facing the family and apologizing yeah, might be a good thing for their own mental health.

It's interesting you say that I'm not going to talk specifics.

Well, I've seen cases like that.

It's almost if you talk.

There is that little bit of adversarial in the inquest and a critical incident, and I see police react like they want to just break down and cry with the family, and it would be benef official for everyone involved, But there's a sort of a stoic front that no, we're fine, we're just doing our job.

And I've heard police in the witness box saying, look, I ran an operation where someone was shot and killed, and I acknowledged that, and I was being cross examined about well, it was a success, wasn't it, And I've said, no, it couldn't be further from the success.

I'm devastated by it.

That was my true belief.

But I've seen police that I think anyone would be of that view stand there and try to put on the brave front.

No, they got what they deserved.

My life felt threatened, and it just aggravates a family traumatized as a family, and I'm sure it traumatizes the police.

So yeah, and I think sorry, I think it is part of the legal advice.

Don't don't concede anything here, and you did the right thing, but you can show emotion and still do the right thing.

Yeah, and even if you did have to act in self defense, and in most of those cases that's exactly what happens, you can say, yeah, but I really regret doing this, and I can see how affected you are.

Kirsten Edwards said, I'm sure you've come across an in quest.

Very very good barrister who I think has sometimes represented police in in quests told me about a case in which she had seen a young cop break down in tears and say something to the effect that to the family.

I think about your son every day of my life, and if I could go back and prevent this happening, That's what I'd love to do.

And the family, the family I think probably wanted to see his pain, not just feel it themselves.

And having and Kirsten Tommy that having seen him breakdown like that, they were much more willing to accept what had happened, to forgive him and to see him as a fellow human being.

And if we can see one another as fellow human beings instead of them and us always you know, you're the other, I'm the strong one, I was just doing my duty or whatever.

I think we go a long way to making these increase a very traumatic for everybody, but we would do a great deal to reduce the trauma that they cause to people, families, police, correctional officers, whoever.

If we could show that, if witnesses could show that they they are her to I think it would be really good if we could get inquests on more quickly, because I think the longer that the time lass.

But yeah, it does.

And people not only come up with their own theories of how this death came about, which can be can be right, but very often wrong.

That can be very difficult for people's mental health as well.

But I think I think there is a I think in grieving psychologically, there's a sort of a sweet spot.

You need some time to get over the initial impact and then you can think about what actually happened, and if you if you can hear from the people who were involved what happened at that moment.

In that sweet spot, then I think you are more likely as a as a fan only of someone who's died, or as someone who was involved in the incident, the fatal incident, maybe even the person who caused the death, I think you're more likely to come up with some chance of healing in maybe not immediately, but over time.

Well, what you're saying there are words of wisdom, and I suppose that comes from seeing the emotions as rule as it is for as long as you did in the environment.

It's confronting.

But what you talk about, I think we could encapsulate that in the word of just bring some humanity to it.

And I mean, I'd like to think that the Police Association and the Public Service Association and those sort of people with the unions would say the benefit of this too, because sometimes I think thinking legalistically is not necessarily the best way to think about these things.

Yeah, and that's exactly how it's approached from the police point of view, and there's so many more layers to it than just from a legalistic point of view.

Another thing that sounds counterintuitive when I say this, but mental health.

And we talked about how that could be navigated if there was someone there with the expertise when police respond to those type of jobs.

But I'm concerned.

I'm saying this now as a former police officer, but seeing what's gone on the lack of training, tactical training.

Now we're trying to reduce police shootings.

Tactical training is not just pulling out a gun and shooting someone.

It's been comfortable in the environment, knowing how to handle yourself, knowing how to de escalate confronting situations.

Police are entitled to use their firearm if they fear for their life.

If we could train people, train police with more training.

Now I'm not sure I've been out for years now, but the amount of training days, tactical training days we do, I think it's one a year, like you have a shoot once a year.

Now, I was involved in tactical policing where we had to shoot the minimum once a month, and it was just so it became repetitive.

You felt comfortable with your weapon from when I joined the police.

And now what the young police are carrying these days, with the tasers, the OC spray, of the expandable battern, and they've got so many other things.

It's complicated in a time of stress, how they're going to react.

I just think we need to and I know there's a cost associated with training police, but we need to dedicate more time to training.

Yeah, well that doesn't surprise me you say that, because almost always in these inquests, the question of tactics comes up, doesn't it.

And you often find that when you boil it down, some of these deaths are ventable and they could have been prevented had better tactics being employed.

So you know, there's training days that I've been up to see how participate in with lesser topic.

Police have shown videos of how to retreat from a dangerous situation, et cetera, et cetera, But how well does that actually work in practice?

And I quite often think about a particular case, this is ut in Western News, South Bales I won't use the man's name because he was an Aboriginal man, but he was shot and killed by police or a police officer.

The police officer was acting in self defense because the Aboriginal man had attacked him with a club block.

But there'd been an earlier incident.

The police were looking for this man and they suspected he was in a house.

And I sometimes wondered how good a job I did as a coroner, because although I had a very good counsel assisting, one of the questions that I later thought about was the tactical issue.

The police entered the house thinking he may be inside.

They entered the room and this man was in there, and the officer pulled out his taser and tasered the man that had, as far as you could see, no effect on you except to mak him even angry.

He had this club like instead of whacking the officer around the head and shoulders, and the officer managed to get his gun out and went bang bang.

Now had the police what I now think is and had we asked for more expertise on tactics, you know, could the police have tactically secured that house better discovered whether or not the man was in the house before they actually entered the room he was in.

I don't know the answer to that, but I kicked myself quite regularly when I think about this, for not having at the time raised the question.

In the end, we walked away.

I'm sorry, you know, terribly sorry.

The man's father was there.

There was a group of Aboriginal people who were very angry, you know, and they saw it as just another day in the colony, I guess something like that.

They could not accept that this death had come about through any thought of anyone except the police.

And I thought, if I now think, if I'd done a better in quest, it may have made absolutely no difference to the community, the Aboriginal community.

We would have got a better answer, I think, and we might have been able to we might have come up with the recommendation that would have made this sort of situation safer in future.

Well, there was a police shooting and going back a very long time ago where tactically it became more contained than negotiat rather than going in with the tactical teams the active shooter scenarios.

Now that's had to be adapted for current times and the threats.

But yeah, I don't think you can get enough training in that type of the type of situation, and you are reacting in what could be the most stressful situation that you've you've encountered, and you need to be able to think clearly, and that only comes through with training.

I think it's something may.

Only happen once in your life.

Yes, please, I've said, but if you can't react instinctively, instinctively in the most appropriate way, can I tell This reminds me of a case that amused me.

Actually it didn't, it didn't have a terrible ending.

And that happened while I was a magistrate.

To police go to go to the door of the house, the knock on the door, they said, please, please, you open the door.

Anyway, they opened the door and a guy comes rushing down the hallway waving a samurai sword and the police officer, I was a magistrate, not a coroner at that stage.

That the guy was charged with dangerous weapon or something like that.

Anyway, the police.

What amused me was this police have a funny way of writing statements.

So and one of the ways they write statements, so that must be taught this in the academy.

Is you don't say.

I said, blah blah, you say.

I said, words to the effect of and this police office.

I said something like I saw a man running down the hallway waving a samurai saw it.

I said, where's the effect of fuck retreated?

I said, words the effect of police Please, we're under arrest.

He said, fuck off.

I've seen statements statements like that.

But yeah, there's training and something stick.

But yeah, I see the funny side of that.

I want no names, no pack drills.

But I went back as a crime manager and there was a young officer and just needed educating, and she was trying to do things properly.

She's given a statement, and I had to go through the briefs of evidence and look at the brief of evidence, and someone brought that to my attention that hey, boss, can you have a look at this evidence of all this brief I've got some concerns, and basically she's gone.

I think it was a domestic situation a I don't say domestics minor, but it was a rather minor thing.

And she's communicating in a level that people would understand.

She's going, well, this is the police officer.

So I said, what the fuck is going on here, and she said, nothing, you bitch.

Don't you call me a bitch, You're the bitch, and like that, like that, And so I got her in to my office and I said, look this statement.

I said, I'm a little bit worried about the wording here.

And she said, we were told in that we've got to say exactly what was said.

And one hundred percent I agree, it's got to be a true account of the conversation.

And so I decided to approach it a different way.

Maybe as a police officer, we shouldn't swear so much, like you that's what said on this occasion, But maybe next time you're speak to a member of the public, don't throw in so many swear words.

But yeah, it's all a learning process, isn't It is a learning process, And I feel, you know, I look back at the mistakes I made in the cops when I just got in and yeah, I don't know how I got through it half the time.

Well, fortunately, coroner's mistakes don't end up with anybody getting hurt or yeah.

Yeah, well that's the thing.

So we've covered off on like critical incidence, and that was a a lot of my time in coroner's courts were put through overseeing critical incidence other cases that you've been involved in the death of fourteen people at Quakers Hill nursing home fire.

That was a horrendous situation.

Do you want to tell us what your involvement overseeing that inquest?

Because it was a person I think he's Roger Dean was convicted of eleven counts of murder.

That's right.

So this situation has happened, the fires were lit, the people at the nursing home were killed.

Homicide have investigated, he's been charged, he's been convicted.

What role did you have as a coroner in that situation?

Well, Conner has always had have a role to look at homicide cases and these were obviously this is a mass murder.

But the reason we could have decided not to do an inquest, this came after the murder proceedings were over.

The reason we decided to do it was for a couple of reasons.

One was, was there anything that we could look at about the management of the nursing home in relation to use of drugs or security of drugs because Roger Dean was doctor shopping.

He has drug affected and the reason he started the fire was to prevent the management of the nursing home finding out about his stealing of drugs schedulate drugs.

So he wanted to cover up his tracks, and he was reckless.

He didn't particularly want to kill people, but he wanted to cover up his own wrongdoing, so he set these two fires and then he ran away turned up later while the fire was being fought.

Were also interested in the response of the fire brigade of how the people were evacuated from the nursing home, whether there were any lessons to be learned about the particular fire, how it's been responded to, the building codes, the actual fire hydrants, and those sort of things, because there had been some difficulties with various aspects of connecting the fire appliances to the water supply and so on and so forth.

So I've forgotten how many recommendations we came up out of that.

It was a significant number.

And one of the main things that in the end we didn't have to recommend because it came out of the case was a change of the building code to require that sprinklers be installed in all nursing homes, because sprinklers can reduce the ambient temperature in a very hot fire enough to save lives.

These sort of fires can get up to incredible temperatures, you know, six hundred degrees one thousand degrees centigrade because they're burning lots and lots of petrochemical materials.

Sprinklers can bring it down to a couple of one hundred degrees, at which point people can be rescued, you know.

Okay, so that's what It's not just saving the building.

It's saving the people is the main thing.

The building could be, but the people could be saying, yeah, yeah, do.

Those recommendations that get followed up where they follow up.

And they were most of them were.

The fire was far and rescue are really good at following up recommendations and in fact, they make a really good contribution to framing recommendations for coroners.

Well, it's important, like the magnitude of yeah, an offense where it's taken for their lives.

It was horrendous that situation.

Some of the strange deaths you've seen, and we're not making light of light of death.

Every death, you know, carries a weight and the impact.

But what are some of the things that you just wouldn't anticipate that's left and the lasting impression on you.

Well, one was, and this was very early on in my time as a coroner.

An elderly man was walking his dog outside Royal and So for hospital, and somehow he got tangled up with the dog, I think, in the lead, and he tripped over and he broke his fema and he ended up in hospital.

Unfortunately, he died of pneumonia, and because it had an accident, his death was reportable to their coroners.

Well, I became hyper vigilant after that when I was working my dog and walking my dog, and if anyone came near me with the dog, I was very, very cautious of it.

I became less hypervigilant and more fatalistic.

I guess after about a year or so.

But you and people stopped reporting this strange man telling the careful when they're walking their dogs.

Oh yeah, so I think I became less strange over time.

I can imagine like things like that that you just never anticipated and okay, it sort of sticks with you for whatever reason.

Yeah, there are others, but I think I prefer not to describe them.

Okay, fair enough.

You explain in part one why you left left as a coroner, and it wasn't by choice, It was just your time to leave as a coroner.

Yeah, since you've left the coroner's court, clearly you haven't.

It's like me, I've left homicide and I'm hosting a podcast called thy Catch Killers.

You have left the coroner's court and you're doing a PhD as cornial matters.

That's right.

So, even when I was working at the coroner's Court, I really felt that the system could be designed and structured and resourced a lot better than it was.

We used to be quite proud of ourselves, you know, proud of the individual work that we did and so on and so forth, but most of us didn't have the opportunity to think much about how the system worked as a system.

And as I was saying right at the beginning of the podcast, Gary, it's a multidisciplinary system.

It's not just coroners.

It's not just coroners telling police to do that or forensic pathologists to do this.

It's a group of people all trying to investigate deaths in the hope of either finding lessons or at least giving people answers.

And I don't think we do it especially well in New South Wales.

The system we have was it's really more or less the same, except on a larger scale than it was in the early nineteen hundreds when the magistrates took it over.

It's still run by the magistrates.

We have better systems in Australia.

There are better systems overseas.

I've heard you say that you rate Victoria as one of the best.

Yeah, what is it about Victoria that sets on the side.

Well, Victoria, Well, a few things.

First of all, it was built around a concept or two concepts really, the two concepts being one care for families.

So everything that coroners do and the coronial system does in Victoria has to take into account the effect on families and their distress.

Secondly, it was all about the second thing is the second pillar is prevention of future deaths.

And in two thousand and eight the Victorian system was reformed from top to bottom.

Well, for many years that had the idea of trying to make it more effective at preventing future deaths and injuries, but the system itself was pretty ordinary, and in fact they had a parliamentary inquiry in two thousand and six which flowed from complaints being made by families about how slow it was, how inefficient it was, et cetera, et cetera.

We have exactly the same sort of system as the Victorians had pre two thousand and eight.

It's not efficient.

The people who work in it are really good people, but they're not resourced well.

The system isn't structured or designed to be effective or as effective as it could or should be.

It's not very good at preventing future deaths.

We only hold one hundred inquests a year, and the only way coroners in Byales have any illegal right to make recommendations to prevent future deaths is if you hold an inquest.

Well, if you don't hold an inquest, there are no lessons disseminated to the community.

There's a lot of data collected and that's sent to a national database in Victoria called the National Coronial Information System, but that's mainly used by university researchers, not so much by coroners, whereas it was set up to help make coroners work really effectively.

The Victorians have an in house research group.

Ontario has an in house research group.

I think Nova Scotia.

No, okay, this is from all your overseas study.

But in New Zealand's looking at it so News up Wales has had two parliamentary inquiries in the last three years or four years which have recommended radical reform.

And basically the reforms being recommended are we set up a specialist court, well resourced with in house researchers, whose job would be to try to come up well first of all, identify patterns of patterns and trends of fatalities, which could then be fed to public health and safety authorities to try to save lives.

And I explained before not only is there an enormous, an incalculable human cost to sudden and unnatural and unexplained deaths, but there is also an economic cost.

If we could if we could make the coronial system in news up Bales even slightly more effective, we could save some lives and the money saved the economic savings would pay for a new system.

The News Out Bail system costs around about eleven million or twelve million dollars a year.

The Victorian system costs around about twenty seven million dollars a year.

That's its compared with what we spend on health, police, public safety.

Generally, you can have a much much better system for not very much more money.

It does seem like peanuts on the scale.

It is peanuts because a constant complaint I've had dealing with victims families is the length of time before the matter becomes and they're hanging there almost in a state of suspense, waiting for this matter.

And exactly if I'm saying in contact, all the inquests that set down for next year, it was going to be this year, but it's been put off for this reason or that reason that needs resourcing, like we need to be able to get the turnover done quicker, would you?

I absolutely agree.

I did some research recently for an article I wrote.

I looked at all the published coronial findings for twenty three and twenty twenty four.

My PhD about forty percent of inquests took more than three years.

It's now it's over fifty five percent.

Now how that break break those figures down?

Fifty five?

Fifty five percent of inquests take more than.

Three years to get finalized.

To get finalized, and more than forty percent take more than five years.

Imagine having to wait that long.

I have a barrister's practicing certificate now and I'm representing a man whose mother died in Orange hospital in twenty twenty one and we still haven't got a date for an inquest.

Were nowhere near.

And he is that because of the availability of a coroner and availability of the court.

Well, it's for all sorts of reasons, the investigations taking a long time, or all sorts of reasons, but there is a tremendous need not just for more resources, but for a better way of coordinating these various arms of the system.

Michael Barnes, a former state coroner, at the parliamentary inquiry in twenty twenty one, gave evidence and he said words the effect of this system is so uncoordinated that it really is a bit of a joke to call it a system at all.

Pretty DAMMI.

And this is Michael Barnes who came down from Queensland.

Michael Barnes who came down from Queensland, who's now the new South Wales Crimes Crossia.

Michael.

Michael really knows all about coroners and coronial systems.

He has seen most of them around Australia.

He's provided advice to many of Australian and I think New Zealand coronial systems and other places.

So Michael is one of the Australia's leading experts.

He knows when he says the system not working, well.

Well we've got to get we have got to get it better.

Haven't we like it?

So I know the trauma that causes families with delays.

Look, I believe the Attorney General has his heart in the right place.

And the problem, of course, as it always is, is resources and that means government money, and that means priority.

There is always enough money.

The question is where does this idea, this concept of a really good colonial system sit in the order of priorities.

And it doesn't sit, in my opinion high enough.

It's time it was improved and radically overhauled.

There's six things and this is in the article that you're the author of.

So I suspect you'll agree with the things.

Six things that need to be done to build a modern coronnial system for New South Wales.

If I could just reimprovement, then we can discuss if you want to one define the philosophy and purpose of the coeronnial system in terms of respect and care for families and prevention of death.

I think we've already spoken about that that was what the whole philosophy.

What's it there for.

To show recognition and respect?

I believe, okay.

Point number two rewrite the Coroners Act.

Yeah, the Coroner's Act is out of date.

It's just a Victoria.

New Zealand.

Other places have much better acts.

It's so obvious a thing to.

Do, okay, So, and that's just making it more contemporary.

The things that need to be changed work better.

O Number three.

Create a specialist Coroner's Court to conduct all coeronnial inquiries and coordinate the multidisciplinary system.

Yeah.

Well, at the moment, cases that occur in the country are reported to LIDCOLN with the specialist coroners work Someone has a look at the case and then it's sent.

In most cases, it's sent back to the country magistrates.

The country magistrates are not specialist coroners.

They don't have the resources, they don't have the training, and they don't have the experience, and yet they're asked, on top of their very busy criminal and civil loads, to look after forty five percent of the state's coronial workload.

It's ridiculous.

Victoria got rid of it years ago.

New Zealand got rid of it even earlier.

Every single Australian state and territory now confines coronial matters the coronial jurisdiction to people who are specialists in that jurisdiction.

Well, I got to say, you've seen here listening to your talk and seeing how you went about your business, and the coroners that I've appeared before, the experienced coroners, You've got so much I call the wisdom but understanding of what's needed in the coroner's court from the experience that you've got.

So it makes a lot of sense.

Point number four.

Focus the system on prevention of death by developing in house research capacity and connecting with other public health research institutions.

Yeah, this is what I'm talking about with Victoria.

Victoria transformed coronial practice really and everyone around the world involved in the niche world of coroners knows this.

Victoria led the way.

It's got some of the leading thinkers about coronial practice.

In Freckleton is probably the leading thinker in the world is a Victorian barrister.

David Rampton is a Victorian forensic pathologist, and they are two of the leading thinkers in in the world on this and both of them have the concept of coigners as public health and safety officials, and that means trying to prevent future debts, looking at what the data are telling you.

Instead of taking samples of one one case or cases one at a time and think, oh, yeah, I've got the answer for that, why don't we look at cases and group them together and look at what patterns and trends are telling us, and then say, what lessons do we learn from this?

How do we stop this pattern or trend recurring?

And that's why I'm saying that the excuse of governments always is we can't afford it.

But if you invested in research like that, or linked up as partners with University of researchers to do this kind of research, the savings would be so honestly incalculable.

You're countering any arguments about what we need the funding.

You're saying, well, look at the model we're talking about.

It would be fiscally responsible.

Do they And I've been talking to the news Outdal's Health about this and they can see that the issue, and I believe the Department of Community, Communities and Justice does too.

It may be that in the next couple of years someone will say, oh, yes, it won't cost very much and this is the bang for the buck we'll get out of it.

It would be a big bang for not very many bucks.

Okay.

Point number five.

Expand the resources and streamline the processes of the system to reduce delay.

I think we've already we've touched and discussed that, and I see the trauma that causes family, so I think that's something that needs to be done the delays.

Could I just so about that?

But here's an obvious thing.

Victoria, almost the same number of deaths reported every year, has fourteen specialist coroners.

New South Wales at the moment has seven.

But I'm told that two of those coroners are going back to the local court to work as general magistrates in September.

I hope that doesn't happen.

I hope.

But even so we've only got seven.

The disparity disparity.

Queensland has ten and they have two thirds of the workload of New South Wales New Zealand, but half the workload of New South Wales has twenty six.

So New South Wales's government is doing coronial work on the cheap.

It's not saving the lives the number of lives it could do if it invested in the system.

It's putting off the evil day.

It's it's the important thing too, isn't it about saving lives?

Ye professional lives, and it's all about carrying the families.

You know, if even if we held more in quests and had more coroners, but you didn't hold them for five years or three years, you might ask, what's the point of holding it an inquest in four years time if the impact by then will have dissipated.

You need to hold in quests within the first couple of years after someone started.

If you're going to learn the lesson and have real impact, I think.

I think you're one hundred percent right point number six.

Minimize unnecessary extra trauma for family members by making inquest processes more restorative and less adversarial.

Yeah, look, I don't think all in quests can be non adversarial.

But I in Ontario back in the nineties, they had this idea of around table kind of a conference.

I don't know if you're familiar with the restorative justice anyway.

Restorative justice means that people who have done something, who have caused a harm, meet the people who have been harmed, and I think we could have a very different kind of coernial system if that became the one of the tools, one of the methodologies where we brought people from hospitals and families together, or from prisons and families together, or police and families together, or whatever it may be.

Accidents people have caused accidents and families together, because as we've explored in this conversation, very often it's not due to malice.

Most often it's not jueitimalice.

You know, homicides are very small proportion of all these deaths.

It's mostly accidental or something of that nature, or a mistake.

If people are willing to meet and open their hearts to one another, that I think could be or could have, but not always, but it could have in many cases a very restorative healing effect.

It's not closure, but it could enable people to go on with their lives in a happier, less troubled way.

Well, I'm a big advocate for restorative justice.

From what I've learned and seeing with people that come in here and lessons that can be learned from it, I think it's something that could be introduced into the cranial sphere.

Yeah, well, if I stay current, that'll be one of the first things I do.

Really, I really would.

And there's one more point.

I think we're talking off a camera that if there's how many cases are reported to the coroner and New South Wales on average a year six just.

A bit under eight thousand now and when I read that, it was about six.

And six and a half from to three years ago, so about eight thousand now.

And we're saying we're talking about the figures that equates to eighty thousand because of there'd be ten people that's been impacted on by someone's death, so and it might be twenty, it might be twenty, so hundred and sixty thousand people.

Look, it's something that what we've talked about, the whole coronial process, it's very close to my heart because I've seen the pain.

I've seen what's gone on and the work that happens.

Ask you a question coming to the end of the podcast.

Do you fear death in what you've seen like examining I think as a homicide detective, I have a certain view on death from what you've seen.

What's your take on death because you've seen it in more ways than most people in their life.

Yeah, well, there are some ways I don't want to die, but I'm not afraid of death as such.

And one of the reasons is early on in my time as a coroner, it took me a while to go down to the morgue and actually see how the forensic pathologists and their teams examined the bodies of those who have died, and it took away the fear of death itself from me.

People are very much at peace.

They're not, you know, whatever happened to them.

They're no longer in pain.

And the other thing about working or getting to know the people in the morgue was I got to know the social workers who deal with the families, and I honestly think they're saints.

They were such good people and such wise and behind people that I thought, you know, I don't know if there's a life after death or not, but at least in this place, those who are dead are at peace, and those who are trying to help their families are really good people.

So it's not such a bad way to go to end up in the morgue.

But yeah, I'm not afraid of my own death.

I really feel though, that we need to save lives.

You know, people we talked about what a good death is.

I would hope our society could ensure as many people as possible have a good death, meaning a death, a peaceful death, a death their families can accept reasonably peacefully.

And I'd say that about our common humanity.

On Sunday there was a march about Palestine.

To me, many people down there, Jews and Palestinians, Israelis and Palestinians.

I think about those people all the time.

Yeah, it's hard not to think about when you see the stuff like we're seeing going on overseas.

It's horrible.

I heard I was at a university graduation and someone doing the talk there.

It was palliative care doctor, and he just spoke and he'd had a lot of experience in palliative care.

And a question was asked of him, what's the most frequent question that people ask you?

What's a good death?

And he said, to live a good life?

And I thought that was a nice way of looking at it, like it's how do you define a good death?

Well, maybe live a good life.

Yeah, it's funny, isn't it.

Three years ago I had a sort of near death experience and while I was waiting for the ambulance, thinking maybe this is it.

That's exactly what I didn't feel.

I've lived a good life.

I felt i'd lived a lucky life, and I had been very lucky.

You two beautiful kids, lovely partner.

I've been lucky enough to do some work that's been really interesting, meet really good people, work with them, and so I thought, you know, if this is the end, I've been lucky.

Were you thinking about whether you should have put in recommendation that ambulances should respond.

I was watching that.

I was watching the clock.

Damn it, I should have made that recommendation strong.

I was actually thinking of that.

Ye.

Hello, how's this going well?

I'm glad we haven't lost yet.

Hugh, And thank you so much for coming on the on the podcast, I've really enjoyed having a chat with you.

But I just want to thank you for the work that you've done.

And at the start of the introduction, I talk about it's there is that you're interested in?

The passionate about is something that I share and I think, whether it's a homicide detective or acurr.

And then we see the pain that families go through where they lose loved ones and they have someone like you with genuine empathy, care and the smarts to get the strong message across.

Congratulations and thank you for your efforts.

Oh, thank you, Garriot.

It's been really interesting and a real pleasure for me to have a chat with you.

It's been a long time.

It has been very good to see you again.

Yep, good stuff.

All the best for the future, and keep pushing, pushing the reform.

Certainly, I'm going home to send a letter to somebody today.

No, it's good and important work that you're doing and a lot of people would thank you for it.

Thank you very much.