Coroner's Finding: HARDING-ROOTS Jeremy Godfrey

Contributing factors

• Deliberate exposure to Fumitoxin (aluminium phosphide) during a siege situation
• Severe depression and suicidal ideation
• Obsessive fixation on former girlfriend after relationship ended
• Failure of police to properly investigate prior incidents of stalking, forced entry, and impersonation of police
• Failure to escalate or coordinate multi-agency response despite clear suicide threats and violence risk
• Mental health management did not include suicide risk assessment despite explicit threats of self-harm
• Lack of restraining order or protective intervention despite request by former girlfriend
• Police classification of criminal trespass and impersonation as routine matters rather than serious escalating conduct

Coroner's recommendations

1. All aspects of domestic violence policing be characterised by a sense of curiosity, questioning and listening, with risk assessment actually applied rather than merely recited as a mantra
2. In cases not formally characterised as domestic violence but involving similar dynamics, all complaints be referred to officers trained in domestic violence risk assessment, with immediate referral to officers of Sergeant rank or above
3. SAPOL General Order Domestic Violence definitions of 'Domestic partner' and 'Close personal relationship' be amended to encompass circumstances similar to those between Ms Rankine and Mr Harding-Roots
4. Police be directed to carefully consider whether complaints in domestic situations involve criminal offences, with investigations into such offences given priority
5. Endorsement of internal SAPOL recommendations from Sergeant Peter Schar's report relating to minimisation of delay in siege and critical incident response