Inquest into the death of Bradyn Stuart Dillon
[2021] ACTCD 3
•29 April 2021
CORONERS COURT OF THE AUSTRALIAN CAPITAL TERRITORY
Case Title:
Inquest into the death of Bradyn Stuart Dillon
Citation:
[2021] ACTCD 3
Hearing Dates:
2-6, 10-13 September 2019, 17, 19-21, and 24-28 February 2020, 10-14 August 2020, 23-27, 30 November 2020, 1 December 2020 (30 days)
DecisionDate:
29 April 2021
Before:
Coroner M.A. Hunter OAM
Findings:
See [3621] – [3625]
Catchwords:
CORONIAL LAW – manner and cause of death – death of a child known to child protection agencies – information sharing across jurisdictions - eyes of the community on the child – reports of bruising – domestic violence - filicide
Legislation Cited:
Coroners Act 1997 (ACT)
Coroners Act 2003 (SA)
Coroners Act 1985 (Victoria)
Cases Cited:
Alphacell Ltd v Woodward [1972] AC 824
Briginshaw v Briginshaw (1938) 60 CLR 336
Chief Commissioner of Police v Hallenstein [1996] 2 VR 1
E & M.H. March v Stramare Pty Ltd (1991) 171 CLR 506Harmsworth v The State Coroner [1989] VR 989
Inquest into the Death of Luke Geoffrey Batty (unreported)Onuma v The Coroner’s Court of South Australia [2001] SASC 218
R v Dillon [2018] ACTSC 164
The Queen v Coroner Maria Doogan; ex parte Peter Lucas-Smith & Ors; the Queen v Coroner Maria Doogan & Ors; ex parte Australian Capital Territory [2005] ACTSC 74.
WRB Transport v Chivell [1998] SASC 7002Texts Cited:
Ian Freckelton and David Ranson, Death Investigation and the Coroner's Inquest (Oxford University Press, 1st ed, 2006)
Representation:
Counsel Assisting
Ms R Curran, Mr M Kamarul and Ms B Morrisroe of Counsel
Counsel for the Australian Capital Territory
Mr J Kellaway of Counsel, instructed by the ACT Government Solicitor
Counsel for the Australian Federal Police
Mr W Sharwood of Counsel, instructed by the AFP
Counsel for the Victorian Department of Families, Fairness and Housing[1]
Ms J Davidson of Counsel, instructed by MinterEllison
Counsel for SK
Mr B Shelton of Tim Sharman Solicitors
Counsel for BU
Mr G Gemmell of Counsel, instructed by HWL Ebsworth
Counsel for PG
Ms K Musgrove of Counsel, instructed by Snedden Hall & Gallop
File Number(s):
CD 33 of 2016
[1] At the time of the Inquest, the Department was known as the Department of Health and Human Services. As of 1 February 2021 the Department of Health and Human Services was separated into two new departments: The Department of Health and the Department of Families, Fairness and Housing. To avoid confusion, I will refer to the Department of Families, Fairness and Housing as the Department of Health and Human Services (DHHS) throughout these findings and to the Department of Families, Fairness and Housing when making recommendations.
Table of Contents
Opening Comments5
Purpose of Coronial Inquest6
Jurisdiction7
History of Criminal Proceedings Relating to Bradyn’s Death11
Inquest Proceedings12
Prohibition Order12
Issues for Consideration12
Family History13Summary of statements and Evidence15
Police Investigation15
Detective Senior Constable NF15
Acting Sergeant MI16
Senior Constable ZL16
Sergeant JR17
Acting Commander KD30
QS - Intelligence Officer, ACT Corrective Services30
Ambulance Paramedics30
Autopsy Report for Bradyn Dillon31
Family Members33SK – Bradyn’s mother33
UN – Bradyn’s step-mother47
BK – Bradyn’s older sister, daughter of SK, step-daughter of Graham Dillon59
JL – Bradyn’s sister, daughter of SK and Graham Dillon60
NE – Younger brother of Graham Dillon60
Neighbours, Friends and Associates of Graham Dillon62
Overview62
TH – Close neighbour of Graham Dillon63
SQ – Friend of Graham Dillon64
TS – Friend of Graham Dillon65
BT – Friend of Graham Dillon66
DT – Friend of Graham Dillon68
SX – Acquaintance of Graham Dillon69
CI – Friend and flatmate of Graham Dillon69
Canberra Fathers and Children Services (CanFaCS)70
BP – CanFaCS worker70
Child at Risk Health Unit (CARHU)80
Doctor OQ – Paediatrician 80
Education Witnesses83
NI – Executive Group Manager, ACT Education Directorate83
SL – Deputy Principal, ACT Primary School 187
OF – Bradyn’s PE teacher, ACT Primary School 293
BE – Bradyn’s classroom teacher, ACT Primary School 293
DI – Bradyn’s classroom teacher, ACT Primary School 293
SU – Principal, ACT Primary School 294
LE – Education Directorate Liaison Officer with CYPS95
Department of Health and Human Services (DHHS) Victoria98
HS – In-house Legal Counsel for DHHS98
XB – Operations Manager at Victoria Child Protection East Division, DHHS99
BN – Team manager of Investigation and Response Team, Shepparton104
CO – DHHS case worker during the Shepparton incident114
DO – Senior Child Protection Practitioner, Shepparton120
CF – Senior Child Protection Practitioner, After-Hours Service121
Shepparton Children’s Court Proceedings124
TQ – Former DHHS Solicitor124
FL – Legal Aid Victoria Duty Solicitor for Graham Dillon141
ZB – Solicitor for SK152
Child and Youth Protection Service (CYPS)162
NL – CYPS Case worker (HP 1)162
KE – CYPS Case worker (HP 3)187
PG – CYPS Case worker (HP 3)197
BD – CYPS Case worker (HP 3)229
EJ – Intake Team Leader241
HC – Intake Officer (HP 3)248
TN – Intake Officer (HP 3)256
TG – CYPS After-Hours Intake Team Leader262
ST – Interstate Liaison Officer268
BU – CYPS Team Leader in the North 0 – 12 Team272
Policy and Procedure Witnesses306
UC – Chief Practitioner Human Services, Officer of Professional Practice306
LT – CYPS Operations Manager316
KO – Principal Practitioner, CYPS327
IQ – Executive Group Manager, CYPS341
Reports and Reviews in Response to Bradyn’s Death351
The Glanfield Inquiry351
The ‘K’ Report357
The Muir Report361
Comments371
Graham Dillon’s Lies372
CYPS – A Nutshell Summary373
What was known to CYPS as at 31 August 2015374Reports and Appraisals375
Bradyn’s School Teachers383
DHHS383
The Experts386Comments in relation to KO388
Policy, Policy Guidelines, and Procedures390
The ‘K’, Muir and Glanfield Reviews390
Causation393
Comments about Filicide and Domestic Violence in General396
Comments about SK and UN397
Condolences398Findings399
Recommendations400CORONER HUNTER:
Opening Comments
1. Bradyn Dillon was murdered by his father Graham Dillon on 15 February 2016.
2. On 15 February 2016, Bradyn was beaten brutally by his father in the presence of his sister, JL. That beating ultimately, resulted in Bradyn’s death.
3. Bradyn had been beaten by his father over a period spanning December 2014 through to his death in February 2016. Those beatings caused injuries to Bradyn over that period. Graham Dillon inflicted serious injuries including subdural haemorrhage, fractured rib, broken teeth, and significant bruises to all parts of his body, including his genitals, between late August 2015 and February 2016.[2]
[2] R v Dillon [2018] ACTSC 164 per Burns J.
4. Bradyn also suffered cigarette burns inflicted by his father to parts of his body. Graham Dillon inflicted these injuries by extinguishing lit cigarettes out on Bradyn’s body. There was also evidence that Graham Dillon pushed Bradyn’s head into a bath holding his head under the water whilst Bradyn struggled to get out (water boarding). There was evidence that Graham Dillon choked his son as well.[3]
[3] Recorded interview with JL
5. Graham Dillon inflicted extensive injuries to his daughter JL using the same or similar methods which included extinguishing lit cigarettes out on her body, pushing her head under water for extensive periods whilst she struggled to get air, choking her, and beating her. There is no doubt that Graham Dillon cruelly tortured both of his children over a significant period of time.[4]
[4] Ibid.
6. Examination of Bradyn’s body at autopsy revealed previously healed fractures and resolved haemorrhages, The Autopsy Report concluded that further beatings around the time of his death caused a re-bleed of the subdural haemorrhage and a re-fracture of his rib, injuries already inflicted by Graham Dillon, some over period of time being December 2014 to February 2016, and in relation to the subdural haemorrhage over a period of at least 8 weeks.[5]
[5] R v Dillon [2018] ACTSC 164
7. After yet another beating by Graham Dillon on the morning of 15 February 2016, Bradyn became rapidly unconscious. Graham Dillon did not seek any medical assistance for his son until many hours later when it was too late for any successful resuscitation.
8. Eventually, it was Bradyn’s sister JL who called 000 at 19:47 hours for assistance. Bradyn was taken to hospital arriving and 20:25 hours. Bradyn was unable to be revived.
9. Not only had Bradyn suffered a further subdural haemorrhage, he also suffered a re-fracture of his 10th rib. Fractures to his teeth were also identified on autopsy. The teeth fractures resulted from significant force applied to his face. The evidence is clear that many of Bradyn’s injuries were sustained from the cruel and repeated beating by his father Graham Dillon.
10. Forensic examination was conducted at the Jacka home where the children lived. The results showed numerous areas of blood spatter identified as coming from both children.
11. Having considered the forensic evidence, autopsy report, and the interview with JL, there is no doubt who caused the death of Bradyn Dillon. Graham Dillon viciously, violently, and cowardly beat his son to death.
12. It is important to note that Bradyn’s sister, JL, had also been brutally beaten by her father.
13. JL also suffered horrendous injuries, including substantial bruising all over her body, cigarette burns to her body, fractured teeth, a severely fractured pelvis and five fractured ribs, all inflicted by Graham Dillon.
Purpose of Coronial Inquest
14. The purpose of a coronial inquest is to independently investigate a death which is referable pursuant to the legislation. The coroner must where possible ascertain the identity of the deceased person, the manner and cause of the death of the person. Included in that finding is the medical cause of the death and the circumstances surrounding the death. Circumstances may include the background and surrounding circumstances to give context to the death if possible.
15. Clearly the legislation confines those findings in respect to those circumstances, to be sufficiently proximate and causally relevant to the death and not merely all circumstances which might form part of a narrative accommodating any death.[6]
[6] Harmsworth v The State Coroner [1989] VR 989 (cited at [55] inquest into the death of Luke Batty 2015)
16. There is a broader purpose for coronial investigation and that relates to matters of Public Safety which is to
‘contribute to the reduction of the number of preventable deaths through the investigation findings and the making of recommendations by the coroners, generally referred to as the ‘prevention role’”.[7]
[7] Inquest into the Death of Luke Geoffrey Batty 2015
17. The evidence in this inquest comprised of 30 hearing days, taking oral evidence from 31 witnesses, 14 folders of material from the AFP investigation team, which included statements, records of interview and the autopsy report. There was also over 5000 pages of material which had been subpoenaed. That material was contained on a USB which was tendered in evidence. There were 149 exhibits tendered in the proceedings. The transcript of the proceedings comprised 2516 pages.
18. Given the enormity of the evidence before me, including oral evidence and materials tendered in evidence, I formed the view that it was important to summarise the statements and oral evidence given by each witness.
19. I also had the benefit of having three reports tendered in evidence before me. The ‘K’ Review[8] was an internal review initiated by CYPS specifically in relation to Bradyn’s death and conducted within 10 days of his death. The Muir report was conducted shortly after Bradyn’s death. This was an external review to review the documents associated with Bradyn’s death. Finally, the Glanfield Inquiry, which looked broadly at the care and protection systems. Each of the reviews made recommendations, which I have considered very carefully. I have attached as an annexure to my findings, the Glanfield Inquiry.
[8] Report Author name suppressed by order of the Coroner
Jurisdiction
20. I have set out the jurisdiction relevant to this inquest.
21. S3BA of the Coroners Act 1997 (‘the Act’) effective as at 16 February 2016 sets out the objectives of the Act.
22. S13 sets out the jurisdiction in relation to coronial powers.
Coroner’s jurisdiction in relation to deaths
(1) A coroner must hold an inquest into the manner and cause of death of a person who—
(a) dies violently, or unnaturally, in unknown circumstances; or all
(b) dies under suspicious circumstances; or
(c) dies and the death appears to be completely or partly attributable to an operation or procedure (other than an operation or procedure prescribed by regulation for this paragraph); or
(d) dies after having undergone an operation or procedure and in circumstances that, in the opinion of the Chief Coroner, should be better ascertained; or
(e) dies and a doctor has not given a certificate about the cause of death; or
(f) dies not having been attended by a doctor at any time within the period commencing 6 months before the death; or
(g) dies after an accident where the cause of death appears to be directly attributable to the accident; or
(h) dies, or is suspected to have died, in circumstances that, in the opinion of the Attorney-General, should be better ascertained; or
(i) dies in custody
23. The evidence before the inquest is clear that Bradyn suffered a violent death and therefore the jurisdiction of the Coroner’s Court is enlivened.
24. The Coroner must find the manner and cause of Bradyn’s death. The cause of Bradyn’s death is not contentious. Graham Dillon murdered his son by brutally beating him over a period of time, causing catastrophic injury which ultimately led to his death.[9]
[9] R v Dillon per Burns J
25. The scope of enquiry available to a Coroner is set out in the decision of Onuma v The Coroner’s Court of South Australia [2001] SASC 218, a case in which the Court considered the scope of the Coroner’s power under the Coroners Act 2003 (SA) and applied WRB Transport v Chivell [1998] SASC 7002.
26. The relevant phrase under consideration was “cause and circumstances”; this compares favourably to the phase “manner and cause” in the ACT Coroners Act. In Chivell Lander J (with whom both Prior and Mullighan JJ agreed) said with regard to the meaning of the word “cause”:
“Clearly enough the cause and the circumstances must be two different things if it was otherwise there would be no reason for Parliament to have included both words. ... The cause of a person’s death may be understood as the legal cause. In determining those events which may be said to give rise to the cause of the death, the coroner is not limited by concepts such as direct cause nor is the coroner limited to a cause which is reasonably foreseeable. The cause of a person’s death in respect of the coroner’s jurisdiction is a question of fact which, like causation in the common law must be determined by applying common sense to the facts of each particular case.”
27. In Lucas-Smith v Ors SC 117 of 2007 Higgins CJ siting in the full court in The Queen v Coroner Maria Doogan; ex parte Peter Lucas-Smith & Ors [2005] ACTSC 74; (2006) 158 ACTR 1 (R v Doogan (No. 2)) where the Court in relation to manner and cause concluded:
“that the range of matters falling within the scope of inquiry, whilst not open-ended, are those that could be considered relevant to determining the cause and origin of the fire causing the damage.”
28. His Honour then went on to say:
All intervening or contributing events may be considered (see R v Doogan (No. 2) [20]).
And at [18] The limiting factor is that of relevance to the issue of cause and origin of the fire process and progress.
29. His Honour then went on to give an example at [19- 20].
“An example of that limitation may be found in the evidence given by the plaintiffs of attempts to obtain government funding for the purposes of community education programs (plaintiffs’ submission [28]). Whilst the Coroner might well comment that lack of such programs contributed to the extent of fire damage, it would be inappropriate for the Coroner to enquire into the reasons for the Government or the Parliament declining funding for such programs.”
30. Those passages are apposite to the present case in respect to all intervening or contributing events with the limiting factor being relevance as to the manner and cause of the death.
31. In relation to standard of proof as to facts found in a Coroners finding, the Coroner is to have regard to the principle laid down in Briginshaw v Briginshaw (1938) 60 CLR 336 as stated by Dixon J at 361-2:
“The truth is that, when the law requires the proof of any fact, the tribunal must feel an actual persuasion of its occurrence or existence before it can be found. ... The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding are considerations which must affect the answer to the question whether the issue has been proved to the reasonable satisfaction of the tribunal.”
32. In relation to the nature of the Coroner’s Inquest, in R v Doogan; Ex Parte Lucas Smith & Ors [2005] ACTSC 74 (5 August 2005) the Full Court of the Supreme Court comprising Higgins CJ, Crispin and Bennett JJ stated at [12] in relation to the nature of the Coroner’s inquiry:
“The task of a coroner is not to determine whether anyone is entitled to some legal remedy, is liable to another or is guilty of an offence. The Coroner’s task is to inquire into the matters specified in the relevant section of the Coroners Act 1997 and make, if possible, the required findings and any comments that may be appropriate.”
33. In relation to the power to make comments, in Harmsworth v The State Coroner [1989] VR 989 at 997, Nathan J discussed the ambit of the Coroner’s power to comment as follows:
“The power to comment arises as a consequence of the obligation to make findings … It is not free ranging. It must be comment ‘on any matter connected with the death.’ The powers to comment and also to make recommendations … are inextricably connected with, but not independent of the power to enquire into a death or fire for the purposes of making findings. They are not separate or distinct sources of power enabling a coroner to enquire for the sole or dominant reason of making comment or recommendation. It arises as a consequence of the exercise of a coroner’s prime function that is to make ‘findings.’
34. In relation to the power to make recommendations, Section 3BA(c) of the Coroners Act sets out the functions given to a coroner.
(c) give the following functions to coroners:
(i) to hold inquests into particular kinds of deaths or suspected deaths, and to make findings about the deaths, including the identities of deceased people and causes of death;
(d) allow a coroner, based on the coroner’s findings in an inquest or inquiry, to make recommendations and comments about the following:
(i) the prevention of deaths;
(ii) the promotion of general public health and safety including occupational health and safety;
(iii) the administration of justice;
(iv) the need for a matter to be investigated or reviewed by an entity.
Subsection (2) As far as practicable, the objects of this Act must be carried out in a way that—
for an inquest into a person’s death—recognises the following:
(c) promotes the development of a systematic and comprehensive public record of findings made by a coroner and any associated recommendations made by the coroner; and
(d) increases public awareness of a coroner’s findings about—
(i) violent or unusual deaths; and
(ii) serious risks to public health and safety; and
(iii) ways to protect public health and safety by reducing the risk of death, fire, or disaster; and
(e) promotes public understanding about the function of the Coroner’s Court.
35. The coroner must make findings in respect to an inquest and where relevant must state if matters of public safety arise in connection with the inquest and may comment on the matter or make recommendations.
36. Section 52 of the act defines what is required or a coroner to find if possible the following;
(a) the identity of the deceased; and
(b) when and where the death happened; and
(c) the manner and cause of death; and
(d)in the case of the suspected death of a person—that the person has -----------died.
(2) A coroner holding an inquiry must find, if possible—
(a) the cause and origin of the fire or disaster; and
(b) the circumstances in which the fire or disaster happened.
(3) At the conclusion of an inquest or inquiry, the coroner must record the -----------coroner’s findings in writing.
(4) The coroner, in the coroner’s findings—
(a) must—
(i) state whether a matter of public safety is found to arise in -----------------------connection with the inquest or inquiry; and
(ii) if a matter of public safety is found to arise—comment on the ---------------------matter; and
(b) may comment on any matter about the administration of justice ------------------------------connected with the inquest or inquiry.
37. It may be that an issue arises as to what is meant by connection with the inquest or connected with the inquest.
38. A helpful statement can be found in relation to that issue in R v Doogan; Ex parte Lucas-Smith [2005] ACTSC 74 whether court said at [29];
“A line must be drawn at some point beyond which, even if relevant, factors which come to light will be considered too remote from the event to be regarded as causative. The point where such a line is to be drawn must be determined not by the application of some concrete rule, but by what is described as the “common sense” test of causation affirmed by the High Court of Australia in March v E & MH Stramare Pty Ltd (1991) 171 CLR 506. The application of that test will obviously depend upon the circumstances of the case and, in the context of a coronial inquiry, it may be influenced by the limited scope of the inquiry which, as we have mentioned, does not extend to the resolution of collateral issues relating to compensation or the attribution of blame.”[10]
[10] R v Doogan Ex Parte Lucas-Smith [2005] ACTSC 74 at [29]
39. Further at [31] the court stated in relation to causation.
“There will, of course, be many cases in which the issue of causation will necessarily involve an examination of a person’s conduct. A coroner conducting an inquest into the death of a person may be obliged to consider whether the death was attributable to accident or homicide. If reasonable grounds emerge for a belief that a person has committed murder, manslaughter, or some other indictable offence the coroner will be required by s 58 of the Act to inform the Director of Public Prosecutions by written notice and the inquest will be adjourned. If that situation does not arise, the coroner will be obliged to make findings as to the nature of the acts and/or omissions that caused the death, even if they reflect adversely on the reputation of one or more people involved in the relevant incident. Hence, a coroner might well hear evidence suggesting that a cyclist’s death had been caused not merely by a collision with a motor vehicle, but also by the antecedent conduct of the driver of that vehicle in failing to stop at a stop sign adjacent to an intersection. However, the limited jurisdiction conferred by s 18(1) would not authorise the coroner to inquire into any perceived failures in relation to general policy relating to the siting of stop signs or the enforcement of traffic regulations. The particular siting and design of the relevant intersection may be a different matter. The application of the common-sense test of causation will normally exclude a quest to apportion blame or a wide-ranging investigation into antecedent policies and practices.”
40. I have very carefully considered legislation and the authorities in respect to the matters which I have set out above.
History of Criminal Proceedings in Relation to Bradyn’s Death
41. On 15 February 2016, Graham Dillon was arrested and charged with the murder of Bradyn Dillon. He was also charged with 3 counts of inflicting actual bodily harm to JL.
42. On 1 September 2016 Graham Dillon pleaded not guilty in the Magistrates Court and was committed for trial to the Supreme Court.
43. On 29 August 2017 Graham Dillon pleaded guilty to 11 charges. Additional charges were also taken into account.
44. The first 6 counts on the indictment relate to charges of murder, threat to kill, choke render insensible, assault occasioning grievous bodily harm, and assault occasioning actual bodily harm in relation to Bradyn Dillon.
45. Graham Dillon also pleaded guilty to 3 counts of grievous bodily harm inflicted upon JL, as well as a charge of choke render insensible, and a charge of threat to kill, in relation to JL.
46. All of the charges relate to offences committed between dates of 7 December 2014 on 16 February 2016.[11]
[11] R v Dillon [2018] ACTSC 164.
47. The agreed statement of facts exhibited before Burns J, for the purposes of the sentencing procedure, outlined the circumstances alleged against Graham Dillon in relation to the charges he pleaded guilty to. These included the circumstances in relation to the charges taken into account.
48. The facts were prepared by the Director of Public Prosecutions and agreed to by Defence. The facts tendered in the proceedings must establish evidence to prove beyond reasonable doubt the elements of the offences as charged. The findings by Burns J reflects that requirement.
49. The facts outlined those behaviours. Those behaviours included that Graham Dillon Inflicted punches, kicks, cigarette burns, as well as waterboarding (pushing the head of the child into the bath and refusing to let the child up to breathe). Graham Dillon also used a belt to hit the children with.
50. The statement of facts also included the facts and circumstances relating to the charges that were taken into account on the indictment.[12]
[12] See Annexure A.
51. A history and chronology of those charges with the relevant factual circumstances in relation to them is annexed to these findings as annexure B.
52. Graham Dillon was sentenced to a total of 41 years and one month on 4 June 2018. That sentence included the murder of Bradyn together with other charges in relation to Bradyn, his sister JL, and his stepmother UN.
Inquest Proceedings
53. The Inquest into the death of Bradyn Dillon commenced on 11 October 2018. 4 months after Graham Dillon was convicted and sentenced in respect to the death of Bradyn Dillon.
54. On 13 March 2019 and 28 June 2019 letters were sent to Graham Dillon advising him of directions hearings in relation to the Inquest. On 12 August 2019, a letter was sent to Graham Dillon, advising him of the commencement of the Inquest. Graham Dillon declined to engage with the proceedings.
55. Sections 58 and 58A of the Coroners Act do not apply to these proceedings. No referral was ever made to the Director of Public Prosecutions in regard to this inquest.
56. Section 55 will not apply in relation to Graham Dillon, given he has pleaded guilty to charges relating to the conduct the subject of this inquest. By his plea of guilt, he admits to the conduct.
57. This inquest has exposed much of what happened in relation to Bradyn and JL while they were in their father’s care. Much of this information was unknown to his Honour Justice Burns, the Crown and even the Defence in Graham Dillon’s sentencing proceedings.
Prohibition Order
58. On 27 August 2019 at a directions hearing, I ordered that all named identified in these proceedings (except for the names Graham Dillon and Bradyn Dillon) be the subject of a prohibition order.
59. That order remains in place and I ordered that the order continue indefinitely.
60. All witnesses who gave evidence in this inquest will have anonymized initials. I have annexed to these findings a schedule of the anonymised identities with an explanation of their role, relevant to this inquest.[13]
[13] See Annexure A.
Issues for Consideration
61. There is no issue as to who caused Bradyn’s death. That fact has been well established. Graham Dillon is the sole person responsible for the murder of his son Bradyn.[14]
[14] R v Dillon [2018] ACTSC 164 [14]
62. The evidence clearly established that Bradyn Dillon and his sister JL were children at risk of harm.
63. Many reports from teachers were made in respect to both Bradyn Dillon and his sister about bruising being found on their bodies and absenteeism from school (which seemed to coincide with those reports of bruising)
64. Prior to my taking over this matter, I note that Chief Coroner Walker, with agreement of the parties identified the issues for determination in relation to manner and cause of Bradyn’s death. Those were:
How was it that Bradyn had become isolated from the community? What was known by the various authorities, and how was that information communicated to those who could action it?
In 2014-2015, the following agencies had intervention with Bradyn:
i.ACT Education
ii.CanFaCS
iii.CYPS
iv.Vic DHHS – Children’s Court
v.ACT Health
vi.AFP – SACAT
How was it that intervention from these entities discontinued? The salient events that this would then permit analysis of 8 includes:
a. Involvement of CYPS from late 2013 including upon the children’s return to ACT in November 2014
b. Attempted intervention from Vic DHHS in November 2014
c. The decision not to investigate by SACAT on return to the ACT
d. Circumstances of CYPS interviewing the children in January 2015 and closing the file
e. The communication of ongoing reports of harm by SK to DHHS from November 2014 to June 2015
f. The failure to recognise and address cumulative harm
g. Capacity for Bradyn to be unenrolled from school in the ACT and remain in the ACT unnoticed. The interagency and interstate communication and information sharing
Family History
65. In order to understand the family dynamics, I have set out a history of Graham Dillon’s family.
66. Graham Dillon met SK in Tasmania in 2002. At that time, SK had a daughter BK, born June 1999. Graham Dillon and SK had two children together, JL born on 3 November 2005 and Bradyn Dillon born on 25 October 2006.
67. Graham Dillon and SK separated because after years of enduring physical abuse SK could take no more and left Graham Dillon. Graham Dillon then moved to Queensland where he met UN in 2007.
68. Graham Dillon lived with, and then married UN and had 3 children with her, a boy born October 2010 and twin girls born 2012. They were living in Canberra.
69. Bradyn and JL came to reside with Graham Dillon and UN for an extended holiday in mid-2013. When SK asked for the children to be returned to her care, Graham Dillon refused to return the children to their mother as pre-arranged.
70. Graham Dillon took out a DVO against SK in 2013, preventing SK from access to Bradyn and JL.
71. There was some confusion in relation to the DVO as SK had applied for the children’s names to be removed. On the Interim Order given to SK, the children’s names had been removed.
72. UN separated from Graham Dillon in April 2014, and he, Bradyn and JL left the home. They were eventually housed by Canberra Fathers and Children Service (CanFaCs) in August 2014.
73. SK removed the children and took them back to Victoria in November 2014 as she held grave concerns as to the children’s safety in the care of Graham Dillon. Graham Dillon sought a recovery order from Shepparton Children’s Court and the children were returned to him by the Magistrate on 17 November 2014.
74. At the time the ACT Registry, under the slip rule added Bradyn and JL (as originally ordered by the Magistrate) onto the DVO. This change to the order was not served upon SK. At the time of her taking the children from the ACT there was no order in place (as far as she was aware) which included Bradyn and JL.
75. The amended order was not served upon SK until she was found in Victoria just prior to the Court case in November 2014. Technically SK was not prevented from taking the children from the ACT at the time she did, because according to the order she had been served with, the children were not named on it.
76. SK was not charged with a breach of the DVO.
77. On 17 November 2014 a Magistrate returned the children to the care of Graham Dillon, on the basis that SK should not be rewarded for breaching the DVO. Unfortunately, the Magistrate was not told of the error made by the ACT Magistrates Court Registry.
78. Bradyn and JL returned to the ACT and lived with Graham Dillon until Bradyn’s death on 15 January 2016.
Summary of Statements and Evidence
Police Investigation
Detective Senior Constable NF – Part of the Homicide Investigation into Bradyn’s Death
Statement[15]
[15] (Evidence pp 25-32).
79. Detective Senior Constable NF was part of the homicide investigation team investigating the death of Bradyn. He assisted in the interview with Graham Dillon and advised him that Bradyn had deceased.
80. Detective NF also interviewed Bradyn’s mother (SK), Bradyn’s step-mother (UN), and Bradyn’s sister (JL). When speaking with JL he made observations of the numerous bruises, lacerations, and injuries which appeared all over her body.
81. Detective NF also assisted other teams in examining the crime scene at the Jacka house with the collection of evidence and information relating to Bradyn’s death.
82. Detective NF recorded an interview with Graham Dillon. During the course of the interview, Graham Dillon admitted that he had struck his son and displayed an attitude of justifying his behaviour as parental discipline of the children.
83. Graham Dillon tended to blame everybody but himself for his actions. Graham Dillon lied about how long it was that he knew Bradyn was unconscious, he also lied about what he did to help his son after he became unconscious.
84. Graham Dillon also lied about the state of the children in respect to the significant bruising and lacerations found on both their bodies. Graham Dillon denied that the bruising was of any great significance. When confronted with photographs of his daughter JL, he initially denied causing most of the bruising but then admitted that probably he caused 90% of them.
85. Graham Dillon then explained that over the past eight weeks prior to Bradyn’s death the children had played up badly and that was the reason why they got punished. Ultimately, he could provide no explanation as to why JL and Bradyn had so many terrible bruises all over their bodies other than that he was extremely violent towards his children.
In Evidence before the Inquest
86. Detective NF provided a statement he had made, together with other documents included in his investigation which were tendered in evidence. Detective NF summarised the information that he received from the Australian Federal Police (AFP) and Ambulance Service in respect to an unresponsive male child, Bradyn, being found at Bitterman Street Jacka.
87. Detective NF outlined the arrest of Graham Dillon and the interview conducted with him. Detective NF also provided the material arising from his investigation which was ultimately tendered in evidence before me. That material was tendered as a single exhibit of 14 volumes of material.
88. Included in the bundle was a document compiled by an intelligence analyst of the timeline of events documenting the history of abuse involving Graham Dillon and his extended family.
Acting Sergeant MI – Property Officer during the Search of 7 Bitterman Street Jacka
Statement
89. Sergeant MI attended the scene at 7 Bitterman Street Jacka. Sergeant MI acted as property officer during a search of the premises.
90. Sergeant MI observed that the residence was a split-level house with two living areas, a kitchen laundry, bathroom, separate toilet and three bedrooms. Sergeant MI described the house as being in a general state of disarray. There were rotten food items throughout the kitchen and garbage which had not been taken out. It did not appear as though clothes had been washed in some time. Sergeant MI observed maggots in various parts of the living and kitchen area around the rubbish and uneaten food.
91. Sergeant MI took possession of drugs found at the home.
92. Sergeant MI also made enquiries at the Bonner shops and the petrol station in Amaroo in relation to potential purchases made by Graham Dillon on 15 February 2016.
Senior Constable ZL
Statement
93. Constable ZL attended Bitterman Street Jacka in relation to the search warrant executed at that address. He observed what appeared to be dark blood spatter on the walls near the bed of a girl’s room. There was a bloodied towel on the floor and a bloodied white kids’ shirt also on the floor.
94. In what appeared to be a boy’s room, Constable ZL observed bloodied tissue on the bedside table. As he exited the hallway, he observed blood spatter on the wall closest to the front of the house.
95. There was a complete investigation into Bradyn’s death by Police from ACT Criminal Investigation. This included forensic evidence being obtained particularly the blood spatter found in various rooms and the bathroom of the premises at 7 Bitterman Street in Jacka.
96. The result of that blood spatter found that the majority of the blood belonged to either Bradyn or JL and in two areas the blood belonged to Graham Dillon.
Sergeant JR – CYPS Liaison Officer
Statement[16]
[16] Transcript of Proceedings, p 422 – 510
97. Sergeant JR was attached to the Sexual Assault and Child Abuse Team (SACAT) and then to the Child and Youth Protection Services (CYPS) as a liaison officer within SACAT. That role allowed referrals from CYPS to the Police. The liaison officer conducts an assessment to determine whether Police will accept the matter for further investigation.
98. The role of a liaison officer was to assess referrals which were then either accepted, rejected, or referred back to CYPS for their action, or allocated to Police for investigation.
99. Bradyn Dillon was first referred to Sergeant JR on 28 July 2014. Sergeant JR indicated that her usual practice was to review the real-time Police indices for entries for the family. There were two entries, one in relation to a threatened kidnap of the children by the mother. The second was an alleged domestic violence incident involving Graham Dillon and his then partner. Bradyn’s sister also had the same entries linked to her name, as well as one in relation to a threatened kidnap by her mother. There was also a breach of a Domestic Violence Order (‘DVO’) from Victoria against Graham Dillon.
100. Graham Dillon had the same entries with three additional matters relating to domestic violence incidents with his partner UN. The three domestic incidents with UN were not progressed and no action was taken. Sergeant JR indicated that at no time was it stated that Graham Dillon had assaulted either Bradyn or JL or any of the other children.
101. Sergeant JR assessed the referral and considered that there was only a suspicion from the teachers because of absenteeism and some unexplained bruising without disclosure. There were no reports in relation to any violence committed by Graham Dillon against the children nor were there any reports he suffered from mental illnesses.
102. Interestingly, Sergeant JR indicated that in her experience it is uncommon for children who are abused to suffer facial injuries because perpetrators usually target nonvisible areas to prevent detection. Sergeant JR opined that children could sustain injuries through accident or misadventure and the explanations provided by the children were plausible.
103. In her view, given the lack of initial information, police involvement would be heavy-handed particularly in a complex family situation where parents need support rather than Police involvement.
104. Sergeant JR opined
“whether there has been a disclosure of abuse or not is only a single factor to consider when deciding whether to accept or reject a referral. It was the combination of the above considerations that support my decision to reject this referral, noting there has been no disclosure of a criminal offence to warrant further Police investigation or involvement at this time.” [17]
[17] statement – paragraph 29
105. Sergeant JR advised CYPS that she was rejecting the referral stating
“as you are unable to identify a specific disclosure this matter is currently rejected. If you receive any further information to indicate otherwise please let me know.”[18]
[18] statement – paragraph 30
106. The second referral came on 4 December 2014. Sergeant JR opined that the report was non-urgent given CYPS had taken 14 days to make the report and it was listed as a non-urgent seven days rating.
107. Sergeant JR noted that it was alleged that the mother had drugged Graham Dillon and taken the children to Victoria, they had been recovered from Victoria and Graham Dillon was given care of them. Sergeant JR also noted that it was the Victorian Department of Health and Human Services (‘DHHS’) who had returned the children to his care. Sergeant JR said she thought if there were serious concerns DHHS would take the children into care.
108. Sergeant JR said that she had experience with parents engaged in custody disputes providing differing versions of events that are averse to the other partner to favour obtaining custody. She said that given the complex family dynamics she had turned her mind to the fact that this could be possible in this case.
109. Sergeant JR also reviewed the report of the Child at Risk Health Unit, which assessed the children with no significant concerns noted. Whilst there was a report that Graham Dillon was using ice, it was not recorded in Police Real-time Online Management System (PROMIS). However, PROMIS did record that SK had a history with ice.
110. Sergeant JR considered that given CYPS were involved in the case Police involvement would be traumatic for the children. Therefore, she rejected the referral and stated to CYPS that she was happy for them to take the lead in the case.
111. Sergeant JR said that she did not receive any further referrals from CYPS.
112. I note the report attached to the statement from CYPS notes that there had been three reports of facial bruising since 17 June 2014 and there had been absences from school which were suspicious. It is also noted that the teachers were very concerned about the bruising and the absences.[19]
[19] my comment
In Evidence before the Inquest
113. Sergeant JR was and still is the community policing liaison officer. In 2014 Sergeant JR was transferred to the CYPS liaison officer role
114. Sergeant JR described the role as a conduit between the SACAT and CYPS. This was done in order to build a relationship between the organisations so that there was a whole of government approach to matters.
115. The system consists of referrals from CYPS or others in relation to non-accidental injuries to children. There is also an element of training for CYPS staff and also policing. Sergeant JR described it as an interlinking relationship.
116. Generally, CYPS would refer the matter to the liaison officer via a generic inbox. This was monitored by the CYPS liaison officer or another Team Leader from the SACAT . The CYPS Interstate Liaison Officer (ILO) would receive between 10 and 30 referrals per week depending on whether it was a peak time such as after school holidays.
117. Following receipt of a referral an assessment was conducted in respect to it. The result was either accepting or rejecting the referral. If the referral was accepted, it would be investigated within the SACAT and either allocated to a general duties person or a SACAT member. The referral would receive a PROMIS number (Police Real-time Online Management System) and then be allocated to a member for investigation.
118. If the referral was rejected CYPS are notified that their referral has been rejected. Once the email is sent to CYPS, Police would upload the report and request received from CYPS to PROMIS within a fortnight.
119. Sergeant JR was asked to think about the factors which are to be considered when analysing whether a referral should be accepted. Sergeant JR was referred to a non-exhaustive checklist provided by Sgt Crocker listing matters to be taken into consideration as to whether a referral is accepted. Sergeant JR agreed that these are the types of considerations used when making that decision.[20]
[20] Sgt Crocker Statement para-A – M.
120. Sergeant JR was taken to the first referral she received on 28 July 2014. Sergeant JR said that while she could not recall exactly, her usual practice was to read the contents and any supplementary notes attached, taking into account the checklist referred to in Sgt Crocker’s statement paragraphs A to M. She would examine who the parties involved in the case were and look up PROMIS and other systems for any records relating to the parents or children.
121. Sergeant JR was taken to the PROMIS note 5458748, July 2014, in relation to a report from Graham Dillon alleging that the children’s mother had threatened to drive to the ACT and take the children. Graham Dillon also advised that child protection Victoria and CYPS were involved and have advised that the children are to stay with Graham Dillon. The note also advised that children’s mother had allegedly been smoking ice and was in a drug induced rage.
122. Sergeant JR was also taken to the PROMIS entry 5511506, in relation to an allegation of domestic violence perpetrated by Graham Dillon to UN. Sergeant JR agreed that it was the information she had at the time of that first referral.
123. Sergeant JR agreed that she also had information about Bradyn’s sister, with two additional entries recorded about an attempted kidnap at the Tuggeranong Hyperdome and a potential breach of a DVO.
124. Sergeant JR also agreed that at the time she had information in respect to a DVO where Bradyn’s mother was the respondent and three domestic violence incidences involving his wife UN. Sergeant JR noted that there was no evidence that Graham Dillon had assaulted any of the children in that history.
125. Sergeant JR outlined the process she undertakes “including reading the information in conjunction with the checks that are conducted and then make an assessment”, these included no specific disclosures made by the children, no specific alerts in respect to violence towards the children, no mental health impairment or illness which would make the perpetrator erratic. In her opinion, children of that age would commonly have bruises sustained through misadventure or accident. They are the types of things that she would consider.
126. Sergeant JR opined that she has experience in bruises that are more likely to be accidental or not. Sergeant JR stated she had worked in the SACAT for 6 and a half years and that there is a commonality between injuries that present and turn out to be abuse and injuries that turn to be accidental. Sergeant JR also utilised her experience as a mother to assist her consideration as to whether the abuse was accidental or not.
127. Sergeant JR opined that an abuser would generally not hit a child in the face in her experience. They would normally be in areas not obvious. Sergeant JR also considered that given the complexity of the case CYPS would be in the best place to investigate the matter before police became involved.
128. Sergeant JR also agreed that she had details of the mandatory reporter as well as a telephone number. Sergeant JR also agreed that the report identified that two children, who were siblings, had bruising to their facial region. Sergeant JR also was aware that when Bradyn was asked about how he got the bruise he could not account for it saying he did not know. There was also the fact that he had been away from school for a week.
129. Sergeant JR stated that this information would ordinarily be something that CYPS would consider because they contact with the schools. It is not something police would get involved in. It was suggested to Sergeant JR that further information on that form indicated that there had been nine such reports in respect to both siblings. All reports were in relation to domestic violence.
130. Sergeant JR believed that the nine reports were in relation to them being present while domestic violence incidents were going on and the domestic violence was not against the children. That distinction made a difference to her.
131. When asked about whether witnessing domestic violence was something to have caused her concern, Sergeant JR considered that it was a child welfare concern rather than a police concern. Sergeant JR confirmed that she rejected the referral but stated that if any further information came forward then CYPS could re-engage with the CYPS Liaison Officer. It was her view that it was more of a welfare concern than a policing concern.
132. Sergeant JR agreed that her reasoning was that because there was no specific disclosure the matter was rejected and therefore it was a matter for CYPS to follow up.
133. In relation to the second referral of 4 December 2014 Sergeant JR understood that CYPS were taking the lead in the matter but sought input from ACT policing. It was her view that they wished to take the lead on that particular matter.
134. Sergeant JR agreed that they were questioning whether police wished to take the lead given there had been previous reports of bruising which she was aware of. It was also reported by CYPS that the children had attended CARHU and there were no significant concerns noted.
135. Sergeant JR stated that she would have access to the CARHU report if she was involved in the matter as it was able to be requested. In this instance she did not see the report from CARHU. Sergeant JR agreed that if they had investigated, they would have seen the CARHU report and the outcomes. Even if the report had indicated that there were unexplained bruises where the children did not make disclosures it would depend on the outcome as to whether police investigated or not.
136. In relation to the 4 December 2014 referral, Sergeant JR was also aware that CYPS was closing the file because the children had been removed from the father’s care by their mother who took them to Victoria. Sergeant JR was also aware that the children were returned to their father and that the children had been interviewed by DHHS Victoria where they had made disclosures of physical abuse. Sergeant JR agreed that that was the first time she had been advised that the children had disclosed physical abuse and agreed that it was significant.
137. Sergeant JR was asked if that information was important, and she said yes however noted that the referral was made two weeks after the children were returned. The concern was that the children were making disclosures of physical abuse by Graham Dillon. Sergeant JR agreed that much of the information of concern came from the Victorian Child Protection workers BN. Sergeant JR had access to contact details for BN, yet she did not contact her.
138. Sergeant JR also took into consideration other factors including that SK had drugged Graham Dillon and had taken the children. Sergeant JR said she turned her mind to the fact that in complex situations parents say things which are not true, particularly where there are custody disputes resulting in parents coaching children to say certain things for that purpose. That was a factor which she had turned her mind to in assessing the information.
139. Sergeant JR agreed that she had been aware that SK had undertaken a urinalysis in Victoria which only detected small amount of cannabis. It was also suggested to Sergeant JR that there had been a toxicology report in relation to Graham Dillon which indicated that he had methamphetamine in his system. Sergeant JR said she had not seen that report. Sergeant JR said that it would not have been on the PROMIS system, however there was a PROMIS reference number for that toxicology results. Sergeant JR advised that the report was something that she would not have seen as it was not part of her investigation.
140. Sergeant JR explained how the PROMIS system works and that all reports are not on the immediate front page and only the front pages would be something that they would look at. Sergeant JR also indicated that she knew about his past criminal history in Tasmania although she did not seek that criminal history.
141. Sergeant JR also agreed that she knew that he had been incarcerated for six months for assault and that his former partner and former wife both had alleged that Graham Dillon was still using ice. Sergeant JR also agreed that it would be a red flag to her. Sergeant JR also agreed that the fact that the urinalysis from SK revealed that she was not taking ice would be significant, particular given the disclosures made by the children.
142. Sergeant JR said the disclosures made to BN was a significant factor. Given the children had been removed from their mother’s care even after disclosures, they would not have had a great deal of trust in police. Sergeant JR said that she was concerned about police being brought into the situation because it would be harmful for the children, and the priority was the children’s welfare.
143. Sergeant JR considered that the best outcome would be for CYPS, who had relationships with the children, could conversed with them and see whether it could obtain disclosures. If it did obtain disclosures, CYPS could take action including removing the children from the care of a predator. In contrast, if police became involved, the children would be scared.
144. I asked whether Sergeant JR had told CYPS of her views and she said she did not believe she had. I asked her how they would know what she was thinking, and she said:
“Because I think that by saying that they would take the lead, that is a known entity without us speaking about it when there's a clear disclosure. It's - I guess because we engage so much that that would be clear to them and clear to us that that is the reason” When you say engage do you mean orally? You talk to them? ---Yes, when we do talk to them. But meaning because we're constantly talking about these things, we're constantly training together, we're constantly having referrals go back and forth, if there is a disclosure that would - to me would be obvious that that would be the reason why we wouldn't be doing it when there is a clear disclosure that the children are being harmed by someone, that would be the case. [21]
[21] Transcript p 440
145. Sergeant JR said that with the existence of those disclosures it was her expectation that action would be taken. Sergeant JR emailed BU advising that she was happy for them to take the lead confirming that they would speak to the family. Sergeant JR also advised CYPS that it was to keep the SACAT in the loop if further information about criminal prosecution comes to light.
146. It was suggested to Sergeant JR that brief analysis on the intake form from care and protection indicated there had been 12 reports in respect of Bradyn and JL, seven received in relation to family violence and the mother’s substance misuse. That since June 2014 there had been five reports of allegations of physical abuse whilst in the care of their father. Sergeant JR agreed that they would be flags for potential intervention considering her checklist.
147. Sergeant JR also considered that the children’s safety was first and foremost in her mind and that referring back to CYPS was the best way to address that.
148. Sergeant JR indicated that while CYPS have undertaken an appraisal and if the children did disclose matters then the police would intervene and interview them. However, if no disclosures were made, the police could not pursue the criminal side of things.[22]
[22] Transcript p 441
149. Sergeant JR was shown that a concern identified in page 5 of the report that read as follows:
“The father presents as volatile and aggressive and has made physical threats to caseworkers and school staff when he finds himself in threatening situations. As a result of threats made against caseworker [NL], the case has been reallocated to another worker.[23]
[23] Transcript p 442
150. Sergeant JR was asked whether this would have been a red flag and of concern. Sgt JR agreed with that but stated that further in the report CYPS advised that the father is engaging with and working well with CYPS. Further if CYPS had concerns they could ask police to attend with them.”
151. Sergeant JR stated that there was no follow-up with the refusal to accept the referral because CYPS would contact the SACAT if there was any concern. Sergeant JR’s expectation was that if the children did make disclosures then CYPS would contact them, and the police could look at the criminal side of the matter.
152. Sergeant JR stated that if Victorian Child Protection services had serious concerns in respect to the children, they would have made an application to have the children taken into care. Sergeant JR was not aware that an application by them had been made in that regard.
153. Sergeant JR said that she did turn her mind to the fact that the children only made disclosures when they were out of Graham Dillon’s reach and that the children may not disclose because they were now back in his care. She thought CYPS would have a better chance than police of getting disclosures from them.
154. Sergeant JR assumed that Victorian police had acted on the application and had taken the children from their mother in Victoria and was not aware that an application to return to the children had been made by the Victorian care and protection service.
155. In respect to whether the rejection of the referral was a clear rejection, Sergeant JR said that her main concern was the welfare of the children and what would be the best way of receiving a truthful account of what had occurred. That would be through a process of CYPS building up a relationship with the children and ensuring their safety rather than through police action, saying:
“I felt that that was the best way to receive that information to try and make sure that the children were safe, to try and get them out of the custody of a person who was harming them versus police interaction, them being more scared, not wanting to talk to us and then them being handed back because not only would CYPS not have the information, they'd have a - from what we've spoken about before, but then what action could they then take and then he would be aware that the children had spoken to police and that might have put them at more risk”[24].
[24] Transcript of Proceedings, p 446
156. Sergeant JR said that it was the usual practice to have CYPS take the lead. Sergeant JR said she did not discuss her reasoning in relation to the refusal of the referral with CYPS.
157. In respect to whether Sergeant JR would have made the same decision, she said that she would have because she believes that police intervention can often spark something like what happened Bradyn and that CYPS were in a better position to keep the children safe.
158. Sergeant JR explained that the way they work has changed and that there is a family violence unit now embedded in ACT policing and that referrals have oversight by the senior member or Team Leader. And if a similar matter was rejected it would be reviewed by the family violence coordination unit as well as oversight by the Sergeant. This process now involves three sets of eyes as opposed to one to assess the situation.
159. Sergeant JR agreed that she had not spoken personally to SK to confirm that she had self-reported use of methamphetamine. Sergeant JR cited that in the second referral there was a reference to the mother using ice in the past but is no longer using and that was the basis of her knowledge.
160. Sergeant JR reflected that even though things at an institutional level may be different it was her view that based on the same criteria and her concern for the welfare of the children she would make the same decision. That is because from a policing perspective, she wanted the children to be safe and that CYPS would continue to monitor them. Added to that was the feeling of distrust between the children and police because of their experience in Victoria.
161. Sergeant JR said that it was because the information she had, was that the children were quite distressed after being taken away from their mother and she believed that was because police were the ones who were there. It was Sergeant JR’s view that that was after they had made disclosures.
162. Sergeant JR also stated that not only was the CYPS worker saying the children did not disclose, but that the teachers also said the children did not disclose abuse. However, they gave examples of how the children were injured. It was her view that CYPS had a good rapport with the children and the likelihood of them disclosing to it was greater than it would be for police.
163. Sergeant JR said she was aware that a child suffering from violence at the hands of a perpetrator who they live with would be reluctant to disclose that abuse whilst they remain living with that person. It was pointed out to her that this reluctance would extend to talking to CYPS and the teachers in Canberra.
164. Sergeant JR did consider there may be means by which the perceived issue could be overcome and that would have been if CYPS spoke to the children and those criminal elements were identified. Sergeant JR agreed that the children were in Victoria separated from their father in Canberra in a different environment and that is where they made disclosures against their father. It was suggested by Sergeant JR that it will also be a new event to give them confidence to speak with police. Sergeant JR disagreed with that proposition because she felt the children would have a negative view of police given that they had been taken from their mother by police and they were distressed by this.
165. It was suggested to Sergeant JR that there was another approach in that the police could investigate by speaking to the children without their father present. Sergeant JR said that was the approach CYPS were to use. However, it was pointed out that was not the case, as the father would be spoken to first and then the children. With all being spoken to on the same day, at the same place. Sergeant JR said that this would not be the case because the children would be spoken to without the father present and in her view the email did not disclose the order of interview, just that it would be on the same day. It was her view that it would be a “fools plan” to speak with the father first and that is not how she would have done things.[25]
[25] Transcript of Proceedings, p 454
166. It was suggested to Sergeant JR that police would be in a far better position forensically to interview children however Sergeant JR replied that whilst they are expert in interviewing CYPS also has skill sets including appraising the situation.
167. Sergeant JR was asked questions in respect to the certificate of analysis of 20 November 2014 showing the presence of methamphetamine, amphetamine, and Ibuprofen. She was asked whether it should have been on the PROMIS notes. Sergeant JR opined that the information should not have necessarily been on the front screen because you can click to where there are documents uploaded. It was her practice to review the front screen when reviewing a job.[26]
[26] Transcript of Proceedings, p 457
168. Sergeant JR said that she was looking to see whether there was a stupefying drug to determine whether he was a victim and said:
“And I guess that obviously why I wouldn't have looked deeper is because what the job pertained to was looking for that - those stupefying drugs, whatever the actual term was, whether he'd been drugged, so it related to him claiming to be a victim of something. So yes, again, I don't know that that would change things if I had have seen that either”[27]
[27] Ibid 457
169. It was suggested to Sergeant JR that it was only the AFP who knew and could prove that Graham Dillon was using methamphetamine in November 2014. Sergeant JR could not comment on that fact, although Sergeant JR accepted that there was information that Graham Dillon was using methamphetamine at the time. The allegation that he was using, she agreed was something that she would accept would require confirmation.
170. Sergeant JR agreed that the certificate on the system confirmed he was taking drugs and contradicted the veracity of Graham Dillon’s narrative about his drug taking. Sergeant JR did not tell the social workers about this information because she believed they had the same information that she did in that regard. However, at the time she was unaware that there was confirmation that Graham Dillon was taking ice.
171. Sergeant JR would not comment on the fact that independent certification that Graham Dillon was using ice was any better information than information from his ex-partners that he was using ice. This information was reflected on the front sheet of PROMIS. In her view it was sufficient evidence to make a call regarding whether care and protection take the matter on versus the police.
172. Sergeant JR clarified that the front sheet did have something in respect to the analysis of the blood and urine to indicate that there wasn’t a stupefying drug in his system however it did not mention that he in fact had other drugs such as methamphetamine in his system. Police were considering it was a prosecutorial factor in relation to Bradyn’s mother rather than Graham Dillon consuming methamphetamine.[28]
[28] Ibid 470
173. Sergeant JR agreed that it may have been better to have added that whilst Graham Dillon did not have any stupefying drug in his system, he did have methamphetamine, however it was still her view that it would not have changed the outcome of her assessment.
174. Sergeant JR identified that she had been the supervisor to a complaint in respect to an alleged kidnapping attempt by the mother at the Tuggeranong shopping centre. She was aware that there were two versions as to what happened that day, that is, abduction versus breach of DVO.
175. Sergeant JR was taken to an interim DVO where allegations were made against Graham Dillon as to his physical and emotional abuse throughout the relationship with SK. These allegations included the fact that he refused to return the children to her and has threatened to kill her if she tries to remove them. It was also alleged that the children were witness to serious physical abuse toward Graham Dillon’s wife. One of the children witnessed Graham Dillon losing control and throwing knives at his wife while she was holding an infant child. SK was concerned in respect to the children’s safety while they were in the care of Graham Dillon.
176. Sergeant JR was unable to recall whether she specifically knew about this application and the account therein. However, she agreed they were very serious allegations. Sergeant JR recalls that she did see an order but was not sure whether it had been withdrawn or that the order only applied to the mother because the children had been placed back into his care.
177. Sergeant JR thought she may have seen the order and was investigating whether it was a conflicting order but does not recall exactly. Sergeant JR was aware that there were issues in respect to his behaviour toward his partners however she did not believe there was any information that he had been violent towards the children.
178. It was suggested to Sergeant JR that the concerns of the mother for the children’s safety would be a relevant consideration. She agreed and said that was even more reason why it was CYPS who should have dealt with the matter as it was a welfare issue rather than a criminal issue.
179. Sergeant JR agreed that Graham Dillon refusing to allow the children to return and threatening to kill anyone who tries to remove them is a relevant consideration, but it was a welfare priority in her view.
180. Sergeant JR agreed that when she was considering whether she would accept the referral, she recalled prominently in her mind that Graham Dillon did not suffer from any mental health issues and that the report from the teachers were only suspicions. However, she did not recall considering the fears that the mother stated she had for the children’s safety if they lived with their father.[29]
[29] Transcript of Proceedings, p 477
181. Sergeant JR did not agree that it was a more prominent feature when bouncing the considerations, but it is one of the considerations and it still would not change her view about how she would have dealt with the referral.[30]
[30] Ibid.
182. Sergeant JR was taken to the reports where there had been bruising noted to both siblings faces which were unexplained. It was suggested that the overall effect of the content of report 70027 was that the children had bruises and they were not talking about them and therefore it was a concern as to whether the bruising was non-accidental. Sergeant JR agreed that was the effect of the report.
183. Despite several matters being reported in relation to the children about suspicions of non-accidental injury, Sergeant JR considered that it was more appropriate to deal with this matter as a care and protection matter in relation to the welfare of the children prior to or rather than police involvement. Once that has been investigated by care and protection and they provide information back to police that is when the Police can act in respect of any criminal matters which are secondary to the welfare matters.
184. It was suggested to Sergeant JR that if a disclosure had been made by a child stating that their father had hit them that referral would not be rejected. Sergeant JR said that it depends on what was said and in what context it was said in, but if there were bruises and there was a disclosure that arose from an assault by a parent then a referral would be accepted.[31]
[31] Transcript of Proceedings, p 483
185. In relation to Sergeant JR’s understanding of police involvement in Victoria the only information was that police found them at the caravan park. There was no information that police had taken them although Sergeant JR believe that the police were there and in fact assisted in taking the children. Sergeant JR accepted that she made no enquiry as to the circumstances of their removal. It was an assumption she had made based on what she had read. Sergeant JR was unaware of any negative sentiment being expressed by either child.
186. Sergeant JR was asked to assume that there was no evidence of police involvement in any traumatic separation of the children from their mother in Victoria. When asked whether that would have changed her decision in relation to the rejection of the second referral, Sergeant JR said it was tricky, but she still does not believe she would have changed her view on the matter given that interaction with police would have been negative.
187. If the children had been comfortable with police and they had disclosed to them then she may have considered not rejecting the second referral. However, she also said
“it’s too difficult to answer that because ‘comfortable’ to me would be that they feel able to discuss the things that they discuss with the DOCS workers that’s comfortable”.[32]
[32] Ibid 488
188. Sergeant JR was asked to assume that the police located the children but left the children with their mother and it was later that the Child Protection workers from Victoria who separated the children from their mother. She was asked whether that would have weighed against rejecting the second referral. Sergeant JR said that possibly she would have had looked at that however she maintained her view that interactions with police have negative connotations particularly if there is domestic violence incidences at home.[33]
[33] Ibid 489
189. Sergeant JR was aware of the provisions of the Children and Young Persons Act 2008 where consent is required by a parent to assess or appraise or investigate matters. However, she was also aware that there is a provision that states agreement is not required in certain circumstances, if there is a suspicion that it is not in the best interests of the children to get that consent.
190. In respect to recommendation nine of the Glanfield Inquiry which recommends removing a requirement for agreement to appraise or investigate, Sergeant JR was asked what her view was in relation to that recommendation. She considered that it would make care and protection’s job a lot easier if they were able to access the children in a manner to be able to protect them and thought it was a positive recommendation.
191. Sergeant JR said she was aware of the prior history of significant family violence which included Graham Dillon spending time in a Tasmanian jail. Sergeant JR agreed that any threats such as those alleged to been made by Graham Dillon in Facebook posts could be regarded as violence against a child. However, she considered that if the children are not direct victims then the issue raised is one of being a welfare issue.
192. Sergeant JR did not appreciate that the AFP held additional information that CYPS did not have and assumed in fact that it was the other way around. Sergeant JR agreed that whilst the AFP have a role in relation to investigating criminal offences, they also have a role in relation to welfare.
193. Sergeant JR agreed that there is room within the system for the AFP to share information with Child Protection and that any opportunity to prevent this from happening again is an important positive step.
194. Sergeant JR was asked whether there was any reason why a SACAT referral should not trigger the kind of proactive information sharing response she described, and she was asked if
“CYPS refers a matter to you, do you agree that that is probably quite a useful time to have a trigger where AFP not only responds to the request to interview, but actually looks at the matter in greater detail and goes through their records and also more proactively shares information back to CYPS so that they can perform their welfare role” [34]
[34] Transcript of Proceedings, p 496
195. Rather than a mandatory requirement it would be a policy process involving a Memorandum of Understanding (MOU). In respect to the CARHU report Sergeant JR agreed that it would be useful for them to have that report in making decisions in respect to referrals.
196. Sergeant JR identified that there is a system on PROMIS which identifies whether there is a DVO in place and has a process where it’s possible to check the details and to determine whether it is active. In respect to emails sent from a Victorian police officer to an AFP officer concerning toxicology report for Graham Dillon given there was one for SK, Sergeant JR could not identify any reason why that could not have been given to Victorian police and nothing which would prohibit her from giving that domestic violence issues and other safety issues for police.
197. Sergeant JR agreed that it would have been good practice for the AFP to inform Victorian police of the results of the toxicology report in relation to Graham Dillon.
198. Sergeant JR agreed that it would be good practice for alerts placed on PROMIS to include things such as confirmed drug use, and when it was confirmed, as well as other useful information such as whether the person is violent or not.
199. Sergeant JR agreed also that could be an alert on the system that there are concerns for children or family’s welfare, but it would have to be at the very high-end of the scale.
200. Sergeant JR agreed in respect to the toxicology report, known to the AFP on 14 November 2014, that would be information CYPS would not have, and it would have been important to confirm the allegations made by SK and UN about Graham Dillon taking ice. Sergeant JR stated that Police would have been able to share that information with CYPS and that it was normal practice at the time to share information of that kind.[35] Sergeant JR agreed that on upon reflection that information should have been conveyed to CYPS.
[35] Ibid 503
201. The time for consideration of a referral appears to be about one and a half hours, which did not include other matters which she may have been dealing with. Sergeant JR agreed and said looking at it today in the detail of the material that was available on PROMIS she could have looked into the matter more deeply.
202. Sergeant JR agreed that given the amount of material, one and a half hours would not have given her sufficient time to look at the matter more deeply. Sergeant JR agreed that if the matter had been conducted more thoroughly further material would have been uncovered which may have been relevant to the CYPS assessment. Sergeant JR also agreed that had CYPS known that information on 14 December or thereabouts they could have shared that information with Care and Protection in Victoria for a court proceeding on 17 November which may have been relevant to those proceedings.[36]
[36] Transcript of Proceedings, p 504
203. Sergeant JR made assumptions in respect to the information that CYPS did hold and was of the view they would have the same information that the AFP had. Sergeant JR agreed that the information in respect to the Victorian DVO would not be something that CYPS would have access to but agreed that it was relevant in this case. Sergeant JR was unsure as to the jurisdictional complexities of whether they were entitled to give that information to CYPS.
204. Sergeant JR agreed that as at 2014, part of the role was to proactively share information through a MOU. Sergeant JR agreed that in this case the toxicology information was not shared, and neither was the Ringwood Magistrates Court DVO allegations shared. She accepted that this information would have been beneficial to CYPS.
205. Sergeant JR identified that an interstate DVO should also come up on the PROMIS system as well as one from the ACT and if Sergeant JR had checked the system for an alert such as a DVO the Victorian order would have come up in the same way that the ACT order would come up. Sergeant JR recalled that she did see the orders.[37]
[37] Ibid 508
206. Sergeant JR said that she does rely on taking the information at face value and relying on its accuracy. However, she does not always believe the truth of each assertion as that would be “the police officer’s curse”. Rather, she seeks to confirm and clarify the point as best she can. However, she has a level of trusting people reporting accurately. Sergeant JR said she would be more inclined to believe the information at face value from Care and Protection workers as opposed to someone who is in a custody dispute. Sergeant JR identified that if a reporter does not have anything to gain, and is a professional, it is more likely that their reporting is accurate.
207. Sergeant JR agreed that she looks at the overall picture on the front screen of the PROMIS system rather than a thorough interrogation the whole of the record.[38]
[38] Transcript p 511
Acting Commander KD – Officer in Charge of the Family Violence Coordination Unit
Statement
208. Acting Commander KD provided a statement exhibited as C 85. Commander KD was appointed OIC of the Family Violence Coordination Unit in October 2015. The unit was created for the purpose of there being an increased focus on family violence within ACT Policing. It was aimed at improving the strategic coordination of operational responses to family violence incidents.
209. Commander KD identified that Bradyn’s death highlighted significant need to review the processes associated with reporting children at risk to CYPS and the operational engagement between CYPS and the AFP.
3566. There was also the issue of contacting the potential abuser and relying on information provided by that person and also the belief that unless the child discloses abuse no further action can be taken. These issues were addressed in the reports with recommendations as to how to improve the system.
3567. The Muir report also identified themes consistent with the themes reported by both Glanfield and K. I have set out the Muir report in summary which outlines those themes identified.
3568. Having considered very carefully the evidence before me together with the three reports exhibited before me, it appears there is a fundamental lack of understanding in respect to application of the legislative requirements and the policy guidelines, when assessing risk of abuse. This could potentially inhibit the ability for a caseworker to make a finding that the children were at risk and therefore in need of care and protection.
3569. The evidence from a number of witnesses suggested that the policies, procedures, and policy guidelines were difficult to access at times and were not well understood. That may reflect why there was a lack of understanding as to assessing risk.
3570. I note that most witnesses had not seen or read either the ‘K’ Review or the Muir report. I found that rather disturbing given the excellent work that had been done to identify the shortcomings and failings attributed to CYPS.
3571. The major conclusion of the ‘K’ Review was important information and should have been disseminated to those at the frontline to better assist them in their task of risk assessment. The conclusion reached was important because it focused on the main part of their casework. It is worth repeating given that a number of the matters identified were conceded by the witnesses in evidence before me.
“the major conclusion reached in the ‘K’ Review was that if more detailed analysis of information, history and risk by the application of a risk assessment, consideration to the impact of cumulative harm, the application of thresholds to inform decision-making, coupled with forensic interviewing of the children and professional judgement based on sound assessment, then it is likely that the intervention pathway for this family’s involvement in child protection would have different”
3572. I also note most of the witnesses had heard of the Glanfield Inquiry but very few had read it.
3573. Having considered all of the evidence as well as submissions by counsel together with the reports I received, I have come to the conclusion that no one could have predicted the outcome that eventuated. It is my view that no one could have predicted that Graham Dillon would murder his son.
3574. Despite the numerous reports which indicated that there was potentially abuse being perpetrated by Graham Dillon, none of those reports could be said to have been a precursor to what eventuated.
Causation
3575. A threshold question in relation to CYPS, was whether, the failings identified by witnesses in their evidence and in the two reports commissioned by CYPS after Bradyn’s death, to examine specifically the involvement of CYPS, had some causal link in relations to Bradyn’s death.
3576. Part of the Coroners function is to find, inter alia, the manner and cause of, in this case Bradyn’s death.
3577. The question as to what that means appears to be a grey area in respect to how far into the “chain of causation” a coroner may go to ascertain the cause of death[1098]. The ACT Coroners Act does not define the concept of causation. Generally, causation is a concept utilised in both the civil and criminal law.
[1098] Freckelton and Ranson Death Investigation and the Coroner's Inquest p 638
3578. Authorities on the position have been referred to already in these findings. They include Harmsworth v the State Coroner, R v Doogan; Ex parte Lucas – Smith and March v E&MH Stramare Pty Ltd. To some extent those decisions have limited how far a coroner might go in enquiring as to the cause of death.
3579. In Chief Commissioner of Police v Hallenstein [1996] 2 VR 1, Hedigan J found a statement of principles enunciated by the High Court in March v Stramare
“applicable to the concept of contribution which within the Coroners’ Act 1985 (Victoria), is concerned with the causes of death and who contributed to it”[1099].
[1099] Chief Commissioner of Police v Hallenstein cited in Freckelton and Ranson page 641
3580. Similar views were expressed by the full Court of the ACT Supreme Court in Doogan Ex parte Lucas Smith.
3581. There are also limits imposed in terms of remoteness of a factor’s impact upon the occurrence of a death. Clearly factors which are anterior to the proximate cause of death contextualise that cause. However, there is no or little helpful authority in respect to the degree of remoteness of enquiry and findings permissible for coroners[1100]
[1100] Freckelton and Ranson Death Investigation and the Coroner's Inquest page 638 – 639
3582. I note, Freckelton and Ranson concluded that
“in practice, the question for coroners’ courts is one of remoteness and it is customarily stated that the distance from the proximate event that the coroner should travel in finding causation is a matter of common sense”[1101]
[1101] Freckelton and Ranson Death Investigation and the Coroner's Inquest page 641
3583. This conclusion comes back to my point that the answer to the question of causation will vary. Common sense seems to be an important factor in deciding that matter. I note that Lord Salmon in Alphacell Ltd v Woodward made the following observation;
“I consider… That what or who has caused a certain event to occur is essentially a practical question of fact which can best be answered by ordinary common sense rather than by abstract metaphysical theory”.[1102]
[1102] Alphacell v Woodward [1972] ALL ER 475 cited in Freckelton and Ranson, Death Investigation and the Coroner's Inquest page 641
3584. I have taken that common-sense approach in determining the cause of Bradyn’s death. That requires consideration of the antecedent factors prior to his death.
3585. I note that the last report made to CYPS by the teachers was in August 2015. That was a period of 6 months between the report and Bradyn’s death.
3586. I have grappled with this issue of causation particularly given it was such a short period of time between the last report and Bradyn’s death.
3587. There have been ‘sliding door moments’ of opportunity during the time CYPS were involved with the children and in particular Bradyn. Opportunities to recognise that the children were at risk of abuse were lost.
3588. A number of factors conspired against Bradyn and his sister. In relation to CYPS, those factors included[1103]
[1103] The K report pages 6-10
a. A consistently minimal application of risk assessment,
b. Practice shortcomings in identifying the cumulative harm of domestic violence upon the children, or failure to note that it was taken into consideration if they did,
c. Practice shortcomings in identifying the thresholds in respect to disclosures made by the children when assessing the risk of harm
d. Practice shortcomings in respect to documentation particularly in relation to the children’s history and risk assessment.
e. Practice shortcomings in investigations into the accuracy of information given by either Graham Dillon or BP
3589. There were other factors at play as well, such as the volume of work at the front end of CYPS in the intake area. That volume was in the order of 18,600 cases last year. That is an enormous number of cases to consider at the intake point. It would be extremely difficult to conduct thorough analysis with that number of cases coming through the door.
3590. In relation to the 2 appraisals conducted by caseworkers, one caseworker had only just commenced at CYPS and had no prior experience but was given the Dillon case. In relation to the other worker, she had only just arrived in Australia and was unfamiliar with the system in the ACT.
3591. During investigation at the intake stage on several occasions there was no investigation involving the mandated reporter, and reliance was placed heavily on the prior reports where it was found that there was no risk of abuse or little risk of abuse and there was a parent able and willing to care for the children, therefore the case was closed.
3592. Reliance was also placed heavily on one source in respect to the family circumstances in relation to community supports and the like. There was no investigation into whether the community supports were in place.
3593. CYPS placed great weight on what Graham Dillon told them. There was no independent corroboration of what he told CYPS. There was little truth in what he told CYPS, but his assertions were relied upon.
3594. Little if any weight was placed on the information Bradyn’s mother and Graham Dillon’s ex-wife gave to CYPS in relation to their experience of significant domestic violence perpetrated by Graham Dillon. That information turned out to be true. Interrogation of Graham Dillon’s criminal history would have corroborated their version in respect to domestic violence.
3595. There was no investigation in relation to the reports made by the teachers on 15 August 2015. Too much reliance was placed on the previous reports where the outcome was ‘no concerns and no further action’. All of these failings or missed opportunities were sliding door moments. The opportunity to thoroughly examine and investigate all of the reports was lost.
3596. The question remains, whether the 9 reports made in relation to the children were sufficient for CYPS to consider taking action, by removing the children from Graham Dillon’s care. Not one of the reports indicated that that was the appropriate course. Collectively not one of the reports considered that the children were at risk of abuse and all of the reports considered that there was a parent willing and able to care for the children. That parent was Graham Dillon.
3597. Those were the lost opportunities, the sliding door moments where they fell through the cracks.
3598. It would be improper to speculate as to what would have happened had those sliding door moments been different. I will not do so.
3599. Did the failure by CYPS to take action during those opportunities contribute to the cause of Bradyn’s death? Is there a sufficient causal nexus between the last time CYPS were involved with the Dillon children and when Bradyn died?
3600. The report of August 2015, was the 9th such report of bruising on Bradyn and JL. Whilst the bruising was clearly significant, particularly given the number of reports of bruising and the absenteeism temporal to that bruising, the nature of the injuries found on Bradyn and also JL were not such that, as at, 15 August 2015 one would anticipate they would be sufficiently predictive of the serious injuries found on the children in February of 2016.
3601. There is a temporal lacuna between that report and Bradyn’s death. In that period of 6 months no child protection organisation or community organisation was involved with the children.
3602. I am satisfied that Graham Dillon intended to purposefully hide the children from the view of mandatory reporting organisations. By unenrolling the children in school, no one had eyes on them. Graham Dillon lied to CYPS and BP about the community organisations that he claimed supported them.
3603. BP had not had any contact with Graham Dillon for some months prior to August 2015.The only eyes on the children were teachers. I am satisfied that is also why Graham Dillon took them out of school and did not re-enrolled them in any other school. I have no doubt that was the purpose of unenrolling the children.
3604. Having considered all of the evidence as well as submissions by counsel together with the reports I received, I have come to the conclusion that no one could have predicted the outcome that eventuated. It is my view that no one could have predicted that Graham Dillon would murder his son.
3605. Despite the numerous reports which indicated that there was abuse being perpetrated by Graham Dillon, none of those reports could be said to have been a precursor to what eventuated.
Comments about Filicide and Domestic Violence in General
3606. Last week there was a news report that a father had killed his 9-month-old daughter by jumping off a cliff. Two women were reportedly killed by their male partners in Queensland, this month the inquest into the death of the Jack and Jennifer Edwards was handed down. Their father followed Jennifer home from school and shot them both whilst they were cowering in their bedroom.
3607. One year ago, Hannah Clarke and her three children died at the hands of her ex-husband, the children’s father. Luke Batty died in 2014 as a result of his father beating him to death. In the ACT we had an attempted filicide of two children by their mother in 2019.
3608. All of those deaths were as a result of family violence.
3609. This inquest is about family violence resulting in filicide. I note counsel for the Territory in his comments at paragraph 66 of his submissions referred to the inquest and the death of Luke Batty. In that inquest his Honour Judge Gray, the then State coroner, opined that having heard from the experts the crime of filicide was a rarity. I would like to think that was true however given very recent news of father’s killing their children it is unfortunately, not such a rarity at all.[1104]
[1104] The murder of Luke Batty, the murder of Jack and Jennifer Edwards, the murder of Hannah Clark and her three children, the suspected murder of Kobi Shepherdson. The attempted filicide of two children in the ACT in 2019.
Comments about SK and UN
3610. I found SK to be a very impressive witness. She was able to give accurate and concessionary evidence when required. It was clear that despite her desperate attempts to engage with various agencies about her well-founded fears for her children’s safety, those concerns fell on deaf ears.
3611. SK said she felt that she was looked down on by those agencies and in my view having considered all the evidence that was probably true. It would appear that this was one reason why she was not able to get the help that she so desperately needed to help her children.
3612. I would like to commend SK and how she did everything in her power to save the children, unfortunately she was not listened to by those who should have listened to her. Ironically as it turned out SK was required to corroborate her version, yet the perpetrator was never asked to corroborate his allegations about SK. That is not an unusual phenomenon. I note what her Honour, the State Coroner for NSW, said in her findings in relation to Jennifer and Jack Edwards about women not being believed when they make complaints about domestic violence.[1105]
[1105] Inquest into the deaths of John, Jack and Jennifer Edwards [49].
3613. UN was a very impressive witness who gave a good history of the historical abuse she suffered at the hands of Graham Dillon. UN was treated with the same lack of respect that SK experienced, perhaps for the same reason. The evidence before me suggests that both witnesses were not believed. The reason, it seems to me, was because of what appears to have been concerns that UN and SK had ulterior motives when making these reports, such as to enhance their success in future family law proceedings. There were no family law proceedings on foot for either SK or UN, and nobody made enquiries to establish that fact. The real situation was that both women were extremely concerned for the safety and welfare of the children. That reason was clearly well founded.
3614. The history of abuse perpetrated against these two women was horrific. Graham Dillon was controlling, manipulative and violent in the extreme, behaviour that is not untypical of violent men perpetrating significant domestic violence against women and their children. Graham Dillon was cunning with his abuse, so as to ensure that both women would not confide with anyone because of his extreme behaviour and their resulting fear.
3615. As history shows us, that behaviour was also deployed by Graham Dillon in relation to both Bradyn and JL.
3616. Bradyn was a quiet and extremely polite little boy. His teachers were very fond of him and described him as courteous and respectful. Bradyn was a child who contributed positively in group situations.
3617. His teachers said that he “consistently contributes to a safe and welcoming class environment and that he consistently contributes to a safe and welcoming playground environment”. I lament that we as a society could not contribute to his safety.
Condolences
3618. I wish to express to SK and JL the courts condolences and sympathy for the loss of Bradyn in these terrible circumstances. By all accounts he was a delightful little boy whose life was cut short by a sadistic monster who was his father.
3619. I would also like to convey that his death was not in vain and there is a legacy that he leaves with us as a community.
3620. That legacy includes learning from the circumstances surrounding Bradyn’s death so that frontline workers get better training in relation to domestic violence. To also find solutions to reduce the scourge of domestic violence upon our community
Findings
3621. Bradyn Stuart Dillon was born 25 October 2006 at Royal Hobart Hospital Hobart.
3622. Bradyn Stuart Dillon died on 15 February 2016 at 20:25 hours at Calvary Hospital Bruce in the ACT, aged 9 years and 4 months.
3623. Death was caused from a closed head injury; the closed head injury was caused by sustained repeated blunt impact injuries over a period of time which were non accidental in nature. The closed head injury was secondary to these repeated impacts.
3624. Graham Dillon, Bradyn’s father, caused the closed head injury by sustained, repeated blunt impact injuries inflicted upon his son Bradyn, which ultimately led to his death.
3625. Graham Dillon was able to inflict sustained violence upon Bradyn (and JL) by deliberately and increasingly isolating them from their community from late August 2015 until Bradyn’s death.
Recommendations
3626. I find that there is an issue of public safety in connection to the death of Bradyn Dillon pursuant to s52 (4) of the Coroners Act 1997. In relation to s57(3) of the Coroners Act 1997 I make the following recommendations:
CYPS
(1) Renewed training initiative with a focus on
i. strengthening the understanding and application of risk assessment, including cumulative harm.
ii. strengthening the understanding and application of legislative thresholds in informing decision making.
iii. strengthening the understanding of forensic interviewing of children and parents.
iv. the role of supervision, to include provision of improved quality assurance of decision making and administrative functions.
(2) Continue funding for the induction training package for new frontline workers.
(3) Funding and investment in training front line managers and team leaders to develop and strengthen skills in risk analysis and quality assurance.
(4) Consider legislative changes in relation to the definition of how a child concern report is defined from a ‘caller defined model to an ‘intake defined model’.
(5) Funding a greater number of staff at the intake level of CYPS.
(6) Funding to be provided for junior staff in intake to develop and enhance their skills in front line work which includes risk assessment and cumulative harm.
(7) Consider the establishment of an Intake Consultation Team for complex cases.
(8) Continue funding of the Case Analysis Team with a view to increasing staff numbers .
(9) Funding to engage a team of trainers in relation to providing mandatory reporters with skills to identify matter which require reporting to CYPS and those which could be referred to appropriate community organisations.
(10) Consider legislative changes to include that mandatory reporters are advised of the outcome of their reports.
ACT Education Directorate
3627. Improvement of school tracking system to strengthen Part 6.1A of the Education Act 2004
(11) Adopt a formal process
i. to require parents to advise the school where a child is being unenrolled to give details of where the child will be enrolled, or home schooled.
ii. where a child, the subject of CYPS involvement, has been unenrolled, to alert CYPS that the child has been unenrolled and the name of the school where they will be enrolled or the address for home schooling.
iii. obliging the Education Directorate to contact the new school to confirm enrolment and if enrolment is not confirmed then the Education Directorate must make a mandatory report to CYPS of that fact.
iv. making child tracking in the ACT to be mandatory for all schools.
(12) To adopt and implement the National Schools Reform Agreement ‘Unique Student Identifier’ (USI) for the purposes of having a national information exchange scheme.
(13) To participate in the management of the interjurisdictional data transfer scheme project through the Education Council of Australia.
Information Sharing Between Organisations and Interjurisdictionally
(14) Expand the usage of the Connect 4 Safety Federal initiative to incorporate a health service provider component .
(15) Continue to evolve the relationships between CYPS, ACT Education, SACAT DVCS and other community organisations through the use of liaison officers.
(16) Enhance information sharing between CYPS and ACT Education in relation to real time enrolment data and identification of children at risk in conjunction with the proposal for mandatory child tracking.
(17) Recommend that the Attorney General at the next meeting of State and Territory Attorneys General, raise with his counterparts the establishment of a national data base for children at risk.
3628. I endorse, and invite the ACT Government to implement, the recommendations from the Glanfield, Muir and K reports and invite the implementation of those recommendations which have not yet been implemented.
I certify that the preceding three thousand six hundred and twenty-eight [3628] numbered paragraphs are a true copy of the Reasons for the Findings of Her Honour Coroner Hunter.
Associate: Georgina Price
Date: 29 April 2021
Annexures (available on the Coroner’s Court website)
Annexure A – Schedule of anonymised individuals and their roles
Annexure B – Charges against Graham Dillon relating to Bradyn and JL
Annexure C – Extract of Bradyn Dillon’s autopsy summarising injuries
Annexure D – The Glanfield Inquiry
Annexure E – Counsel Assisting’s Submissions
Annexure F – Counsel for the ACT Submissions
Annexure G – Counsel for the DFFH Victoria Submissions
Annexure H – Counsel for the AFP Submissions
Annexure I – Counsel for SK Submissions
Annexure J – Counsel for PG Submissions
Annexure K – Counsel for BU Submissions
Annexure L – Counsel Assisting’s Submissions in Reply
Annexure M – Counsel for the ACT Submissions in Reply
Annexure N – Counsel for PG Submissions in Reply
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