OFFICE OF THE STATE CORONER FINDINGS OF INQUEST
CITATION: Inquest into the deaths of Antony WAY Tania SIMPSON Kyla ROGERS Paul ROGERS Coroner’s Court Brisbane COR 2011/1619, COR 2011/1640 COR 2011/1641 21 June 2012 Southport 18-20 June 2012 Mr Michael Barnes, State Coroner CORONERS: Murder/suicide, domestic violence 2011/1620, COR

TITLE OF COURT: JURISDICTION: FILE NO(s):

DELIVERED ON: DELIVERED AT: HEARING DATE(s): FINDINGS OF: CATCHWORDS: REPRESENTATION: Counsel Assisting:

Mr Peter Johns Mr Craig Pratt (Gilshenan & Luton Legal Group) Mr Ian Fraser(QPS Solicitors Office)

Sergeant Robert Smithson:

QPS Commissioner:

Table of Contents Introduction _________________________________________________________1 The investigation _____________________________________________________1 The inquest __________________________________________________________2 The evidence_________________________________________________________3
Social histories __________________________________________________________ 3 Relationship between Paul Rogers and Tania Simpson _________________________ 4 The separation __________________________________________________________ 5 Mr Rogers reaction to the separation________________________________________ 6 Contact with QPS________________________________________________________ 8 Contact with other agencies ______________________________________________ 10 Events immediately prior to the deaths _____________________________________ 12 The killing of Anthony Way and Tania Rogers_______________________________ 13 Discovery of the deaths __________________________________________________ 14 The search _____________________________________________________________ 15 Rogers and Kyla are found _______________________________________________ 17

The investigation findings _____________________________________________17
The autopsies __________________________________________________________ 18

Findings required by s45 ______________________________________________20
Identity of the deceased ________________________________________________________20 How they died _______________________________________________________________20 Place of death________________________________________________________________20 Date of death ________________________________________________________________20 Cause of death _______________________________________________________________21 Kyla Rogers died from asphyxia._________________________________________________21

Concerns, comments and recommendations_______________________________21
The connection between domestic violence and homicide ______________________ 21
Scale of the problem __________________________________________________________22 The characteristics of deadly relationships _________________________________________22

Opportunities for intervention in this case __________________________________ 24
QPS D&FV policies in February 2011 ____________________________________________24 Were they complied with? ______________________________________________________24 Lawyer’s response ____________________________________________________________25 The psychologist’s response ____________________________________________________26 Relationship Australia’s response ________________________________________________26

Child abduction alert ____________________________________________________ 26
QPS policy on child abduction alert_______________________________________________26 Were the policies complied with _________________________________________________27

Current QPS D&FV policies______________________________________________ 27 Is further reform necessary?______________________________________________ 28

Conclusions and recommendations______________________________________28
Recommendation 1 – Continuation of the DFVDRU _________________________________30 Recommendation 2 - DV Protective Assessment Framework. __________________________30 Recommendation 3 – Don’t wait for physical violence ________________________________31
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The Coroners Act 2003 provides in s45 that when an inquest is held, the coroner’s written findings must be given to the family of the person who died and each of the persons or organizations granted leave to appear at the inquest. As this inquest dealt with the death of a child the findings must also be distributed to the Children’s Commissioner. These are my findings in relation to the deaths of Antony Way, Tania Simpson, Kyla Rogers and Paul Rogers. They will be distributed in accordance with the requirements of the Act and posted on the website of the Office of the State Coroner.

Introduction
Late at night on 15 May 2011, Paul Rogers went to the home unit of his recently estranged partner, Tania Simpson, broke in and stabbed to death that former partner and a male friend of hers, Antony Way. He then carried his 5 year old daughter Kyla to his car and drove south into New South Wales (NSW). Early the next morning, he pulled off the Bruxner Highway just west of Casino and killed his daughter and himself. These findings:• • • establish the circumstances in which the fatal injuries to the four deceased persons were sustained; confirm the identity of the deceased people, the time, place and medical cause of their deaths; consider the interaction between Ms Simpson, the QPS and other agencies from which she sought assistance in the months prior to her death; examine the adequacy of the QPS and NSW Police Service response to the abduction of Kyla Rogers; examine statistical data and academic research on the links between domestic violence and homicide; and consider whether changes to the policy or practice of the QPS and other agencies in relation to their dealing with matters of domestic violence may prevent similar deaths.

• • •

The investigation
Although two of the deaths did not occur in Queensland, the NSW State Coroner, Magistrate Mary Jerram, agreed that I should assume responsibility for the investigation of all of the deaths as the majority of the evidence to be considered related to events that occurred in this state.

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Thereafter the Lismore coroner and members of the NSW Police Service cooperated with the Queensland Police Service (QPS) detectives investigating on my behalf. It was quickly established that Paul Rogers was solely responsible for all of the deaths. Accordingly, no prosecution was possible but the detectives involved set about conducting an extensive coronial investigation That investigation was exhaustive. Its results are summarised in this report. It commenced with a detailed forensic examination of Ms Simpson’s unit and the car in which her daughter Kyla and Mr Rogers were found by scientific officers. It included internal autopsies on all four bodies; interrogation of the mobile phones used by the deceased adults and others associated with them; viewing of cctv recorded vision and traffic cameras along the route Mr Rogers was suspected of taking when he abducted his daughter; interviews with numerous family members, friends, health care professionals; lawyers; police officers and business people those who had contact with the deceased in the months before their deaths. Detective Senior Constable Kayleen James’ investigation report was of a high standard. I commend her and those who assisted her on their endeavours. A review was also undertaken by officers from the Domestic and Family Violence Death Review Unit which is comprised of a police officer and social science researcher and is located within the Office of the State Coroner. The rationale for the unit and its activities are described later in this report. That unit reviewed the investigation material from a prevention perspective and provided a report summarising relevant research literature and applying its findings to the circumstances of this case. In particular the unit’s report critiqued the adequacy of the responses and support provided by QPS and other agencies to the behaviour of Paul Rogers after his separation from Tania Simpson; it questions whether civilians who were aware of various concerning aspects of the case could have reacted more effectively. The reports conclusions are summarised later in these findings. I commend the authors, Dr Michelle Hayes and Sergeant Paul Dalton, for their insightful and constructive analysis.

The inquest
The inquest took place over three days at Southport. Mr Johns was appointed as counsel assisting and leave to appear was granted to Sergeant Robert Smithson and the Queensland Police Commissioner. Eleven witnesses gave oral evidence and 462 exhibits were tendered. One of the witnesses was John Simpson, father of Tania. I acknowledge his bravery in participating in what was clearly a very painful process and his altruism for doing so in an effort to reduce the likelihood that other families will suffer as his has. Tania’s mother Julie Anne Simpson also attended the
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inquest. The mothers of Paul Rogers and Antony Way were kept informed about the inquest process and Mrs Rogers wrote to counsel assisting acknowledging this and providing some further details about her son’s background.

The evidence
I turn now to the evidence. Of course I can not summarise all of the information contained in the exhibits and transcript but I consider it appropriate to record in these reasons the evidence I believe is necessary to understand the findings I have made.

Social histories
Antony Paul Way was born in New Zealand on 13 December 1977 and so he was 33 years of age when he died. After leaving school at 15 he worked as a labourer. Mr Way moved to the Gold Coast in 2003 where he obtained work as a labourer and later as a qualified plasterer. Shortly after his arrival Mr Way met Paul Rogers on a building site and got on well with his fellow New Zealander. He became friendly with Mr Rogers and his then girlfriend Tania Simpson and maintained contact with them over the ensuing years. Mr Way did not marry and had no children. For most of the two years prior to his death he lived in a de facto relationship with a woman in Carrara. It seems clear that in early 2011 the nature of his relationship with Tania changed. He moved out of his partner’s house in mid May. He stayed at a friend’s place and at Tania Simpson’s unit for the two nights before his death. Mr Way is survived by his mother Betty and his brother Andre. Tania Lee Simpson was born on 4 February 1980 at Innisfail and was 31 years of age when she died. After completing her schooling in 1997 she studied animal husbandry at Gatton Agricultural College for a period before returning to the Gold Coast where she obtained qualifications in hospitality operations, tourism and retail travel sales and, in 2006, a Real Estate Institution of Queensland management rights licence. Between 2002 and 2010 Ms Simpson was in a relationship with Paul Rogers the details of which are set out in more detail below. Ms Simpson gave birth to her eldest child, Kyla, in April 2006 and a son, Bronnson in July 2009. In the weeks prior to her death Ms Simpson had moved into new accommodation in a unit complex at Robina where she also held the management rights. She was looking forward to supporting her family through management of the complex and moving on from the upheaval of her separation from Mr Rogers.

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Tania Simpson is survived by her parents, her younger brother and sister and her son. Kyla Anne Rogers was born on 19 April 2006 and was five years of age when she died. Kyla was the eldest child of Tania Simpson and Paul Rogers and had commenced prep at Robina State School in the 2011 school year. Kyla was residing with Tania Simpson in the period prior to her death and was often cared for by her maternal grandparents. Her father had access to her for several hours each Saturday through an informal arrangement with Tania Simpson. Paul Anthony Rogers was born on 4 January 1971 in New Zealand making him 40 years of age when he died. In the ensuing years he travelled between Australia, New Zealand and the United States playing rugby and working in a variety of jobs. In 1997 he began a relationship with a woman he had met on the Gold Coast where he settled, taking up security work. They were married in 2001. The inquest heard that Mr Rogers began relationships with two other women, including Ms Simpson, in 2002 and he was divorced in October 2003. Mr Rogers had completed a TAFE justice program and sought to join the QPS in 2005 but was refused entry due in part to his being charged in 1997 with assault occasioning bodily harm and later committed for trial for that alleged offence. The trial did not ultimately proceed. He was listed as a suspect in two other alleged assaults arising out of his employment as a “bouncer”. These matters, along with his failure to disclose a traffic offence, were fatal to his aspirations to join the police. In 2007, Mr Rogers and Ms Simpson moved to Inverell to manage a caravan Tania’s parents had then recently purchased. When Ms Simpson separated from Mr Rogers in October 2007, he followed her to the Gold Coast where he bought a vehicle using money given to him by Tania Simpson’s father as part of a property settlement between the two. In the months prior to this death Mr Rogers was living either in his car or with acquaintances.

Relationship between Paul Rogers and Tania Simpson
Paul Rogers and Tania Simpson met in 2002 while both were working at the Lone Star Tavern on the Gold Coast. Mr Rogers was married, although in the process of separating from his wife, and was seeing another employee of the tavern, Amanda Rizzo, at the time. Mr Rogers and Ms Simpson began a relationship and the two moved into a unit at Carrara together in 2004. In April 2006 they had their first child, Kyla and in January 2007 took over the lease on a caravan park at Inverell owned by Ms Simpson’s parents. Mr Rogers and Ms Simpson managed the caravan park for around two and a half years.
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The inquest received evidence from several sources that from early on in their relationship, Mr Rogers displayed serious signs of controlling behaviour. He was noted to actively discourage Ms Simpson from socialising with friends and was very demanding of her. When they moved to Inverell he apparently failed to pull his weight in the management of the park or in caring for the children. Ms Simpson would later tell a psychologist that she felt like a “single mother” during this period and, in addition, ended up doing the majority of the management tasks at the park. In early 2009 the couple travelled to the Gold Coast so Ms Simpson could have a scan relating to her pregnancy with their second child. Mr Rogers failed to attend the hospital for the scan and Ms Simpson later told her family she suspected Mr Rogers had used the trip to the Gold Coast to meet up with his former girlfriend, Amanda Rizzo. Ms Simpson later told a friend that Mr Rogers had been unfaithful to her during this period and when she had challenged him directly in relation to this she was met with a denial. Ms Simpson’s suspicions continued and were confirmed when she called Ms Rizzo some months after the January trip. Ms Rizzo gave evidence that during this phone call she told Ms Simpson that she and Mr Rogers had slept together on one occasion but that she had no interest in pursuing a relationship with him. Ms Rizzo told the court that when she resumed contact with Mr Rogers in late 2008 or early 2009 she directly asked him whether he had any children. Mr Rogers told her he did not. Ms Simpson also became aware that Mr Rogers was using internet dating sights during 2008 and early 2009. When challenged on this Mr Rogers appears to have offered unbelievable explanations of “doing it as a joke” and wanting to prove he wasn’t gay. It is unlikely Ms Simpson believed this but, as will become a theme in the events that followed, seems to have accepted the status quo of the relationship for the benefit of others; especially her children. The couple’s second child, Bronnson was born in July 2009. Ms Simpson later told a psychologist that in the following year Mr Rogers did not take on any child care duties and had limited involvement with the children.

The separation
It was clear to Julie Simpson, Tania’s mother, and some of her friends that Tania was not happy in the relationship. It is unlikely that the announcement by Tania in June 2010 that she was to marry Paul in January the following year was met with enthusiasm despite an enormous amount of goodwill from her family and wide circle of friends. The wedding plans failed to halt the decline of the relationship. Indeed it accelerated over the following months such that by mid October Ms Simpson called the wedding off and moved, with her children, to her parents’ unit on the Gold Coast leaving Mr Rogers at Inverell.
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Cassandra Bargh, a childhood friend of Ms Simpson and now a NSW police officer, gave evidence at the inquest. She said that when told this news she expressed her relief to Ms Simpson that the relationship was finally over. Mr and Mrs Simpson were travelling in north Queensland when told of the separation. They promptly returned to the Gold Coast and Mr Simpson drove to Inverell to oversee the management of the caravan park. It seems it was clear at that early stage that Mr Rogers was unlikely to adjust to the separation and was unable to manage the park alone.

Mr Rogers reaction to the separation
As will become apparent, it was Mr Roger’s failure to adjust to the separation that led directly to the deaths investigated by this inquest. For that reason some detail of that reaction is relevant to an understanding of the tragic events. A few days after Mr Simpson arrived at the park, he became aware that Mr Rogers had left the front office of the caravan park without informing anyone. Some hours later Mr Simpson received a call from his daughter, Tania. She was clearly very upset and told him that she had received a text message from Mr Rogers that was obviously intended to suggest he was about to commit suicide. After closing up for the evening Mr Simpson heard Mr Rogers return and asked him where he had been. Mr Rogers said he had been “out bush” and when asked about the text message he initially denied having made any contact with Tania. After Mr Simpson persisted, telling Mr Rogers of the phone call from his daughter, Mr Rogers’ only response was to ask “was she crying?” This apparent attention seeking behaviour was repeated a few days later when Julie Simpson and Tania Simpson travelled to Inverell to collect some belongings. The three members of the Simpson family stayed the night of 25 October 2010 at the caravan park. The dynamic at the time is reflected in the fact that before going to bed, Julie Simpson wedged closed the door to their residence with chairs because she thought Mr Rogers would attempt to gain entry during the night. Her concerns were well founded. Mr Rogers indeed attempted to enter in the early hours of the morning. He was ultimately allowed in. It appears that his main purpose was to manufacture a situation where Tania saw him without his shirt. This meant she would notice, as she did, cuts across his chest which Mr Rogers disclosed were the product of selfharm. After leaving Inverell, Mr Rogers took up residence on the Gold Coast, although it was not clear to Ms Simpson exactly where. In December he visited the United States for a few weeks and then again returned to the Gold Coast. It appears that he spent the following months moving between a friend’s house, Ms Rizzo’s apartment, a hostel and sleeping in his car. Eventually he moved more permanently into the apartment of Ms Rizzo although this was a wholly plutonic arrangement made in circumstances where she could see he had no where else to go.
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Shortly after his arrival on the Gold Coast, Mr Rogers requested time with his children. No formal access arrangements were ever put in place. Ms Simpson agreed to allow Mr Rogers to see the children for several hours each Saturday. Although on its face such a short period of time of access for a father where there is no Family Court order in place might seem miserly or grudging, it will soon become apparent that the arrangement was in fact generous. Ms Simpson would become extremely stressed as each Saturday approached, to the point that she would be physically ill. Friends and family would notice her appearance and demeanour change markedly as each Saturday approached. That is understandable, having regard to repeated incidents of disturbing behaviour on the part of Mr Rogers, including though not limited to the following:• Refusing to tell Ms Simpson where he was taking the children during Saturday access visits and refusing to give her contact numbers. He would often return the children late (although not excessively) during these access visits. Having tattooed on his chest the words “My loves: Tania, Kyla, Bronnson”. Regularly following Ms Simpson in his car in order to keep check on her movements and who she was seeing. Following Antony Way and loitering around the gym where he worked as a personal trainer. Mr Rogers appears to have formed a suspicion as early as December 2010 of a relationship between Mr Way and Ms Simpson. Sitting in his car for long periods near the residence of Ms Simpson. In many cases this was done with the purpose of joining Mr Simpson, Kyla and Bronnson when they went for a walk. Although this contact was not agreed to Mr Simpson never refused requests from Mr Rogers to join them on the walk. Repeatedly calling and sending text messages to Ms Simpson, often with direct pleas to resume their relationship. During phone calls and in their limited face to face contact, breaking down into a “blubbering mess” such that it would cause upset to Kyla if she was present. Attending Kyla’s school in January 2011 (during school holidays) and carving his and Kyla’s initials surrounded by a heart on a tree in the playground. He showed it to Kyla and told her she could go there if she felt sad or was missing him. He also told Ms Simpson he had done this. 7

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•

• •

•

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Persistently asking Ms Rizzo to withdraw her (truthful) statement to Ms Simpson in the telephone call referred to above, that she had slept with Mr Rogers on one occasion in 2009. On his plan, Ms Rizzo was to tell Ms Simpson she had lied about this to upset her. Ms Rizzo told the inquest that Mr Rogers was fixated on this issue, appearing to believe that it was the sole, or at least, main obstacle to the relationship reforming. Ms Rizzo refused these requests. Attending at her place of work and approaching her in the car park at night. Threatening Tania on one occasion that he would kill her and take the kids. This disclosure was made by Ms Simpson, as far as is known, only to one friend in the context of being asked why security was so important to her when searching for a new apartment.

• •

The disclosure made by Ms Simpson in the last point above was very much the exception. She told others of her concern that Mr Rogers was not looking after the children properly rather than any fear for her safety. Indeed fears for her own safety were never raised with her immediate family, police or counsellors. The evidence heard at the inquest suggests Ms Simpson did not fear face to face contact with Mr Rogers, even alone, at any time.

Contact with QPS
On 15 February 2011 Julie Simpson left the unit complex where Ms Simpson and her children were staying. She drove to Broadbeach where she and Mr Simpson had temporarily moved. It became apparent a vehicle was following her. She recognised it as the Holden Viva Station Wagon of Mr Rogers. She confronted him and demanded to know why he was following her. He denied he was and concocted a story about meeting a male friend at the set of units outside which he had parked. Julie Simpson pressed him on this claim to the point of demanding he produce the friend. Mr Rogers kept up his charade, knocking on the door of an apartment only to have a woman answer, whom, of course, he had never met. Initially claiming that this woman was his friend’s wife and that his friend was not home, Mrs Simpson demanded to hear that from the woman herself. A short time later the woman emerged from her apartment and, unconvincingly, told Mrs Simpson she was the partner of Mr Roger’s friend, making up a name along with answers to further questions Mrs Simpson posed. Mrs Simpson was unconvinced but did not take matters any further. Investigators later spoke to this woman and her statement was tendered at the inquest. She says Mr Rogers pleaded with her to go along with his charade, offering her money and/or wine as reward. The only persuasive aspect of his plea came when Mr Rogers said that the woman outside was trying to stop him seeing his kids and that he would lose access to them if she did not pretend to be his friend’s partner. She described Mr Rogers as desperate and so she agreed to his request.
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Mrs Simpson reported this to her husband and daughter. It was decided that things had deteriorated to the extent that they should contact the police. The following afternoon Tania Simpson telephoned Broadbeach police and spoke to the shift supervisor, Sergeant Robert Smithson. He recorded the following note in the shift supervisor activity log following the call which lasted for 18 minutes: Phone call from Tania Simpson requesting advice regarding her exfiancé, Paul Anthony ROGERS 04/01/71. Rogers has been hanging around Simpson’s address at Nobby Beach on the pretext of having contact with their young children. Simpson has concerns as to mental state of Rogers. In his statement dated 7 July 2011, Sgt Smithson added the following: Tania told me their relationship had broken up or was in the process of breaking up but Rogers was still trying to resolve things. She was concerned regarding the mental state of Rogers. I seem to recall that Tania spoke more about her mother having more concerns than Tania did herself. Tania did not express concerns for her own safety, she was more worried about Rogers just ‘hanging around’ and trying to get the relationship back on track. At the inquest Sgt Smithson could not recall whether he had been told about the events involving Mr Rogers and Julie Simpson the day before although such a conversation would be consistent with the extract from his statement set out above. He told the inquest that he would have taken Ms Simpson through the legislative definition of “domestic violence” and given her advice on the options for obtaining a Domestic Violence Order if the relevant criteria were satisfied. He obtained Ms Simpson’s permission to call Paul Rogers. Mr Rogers returned a message left for him by Sgt Smithson within 6 minutes. The officer gave this account of the conversation: I spoke with him for about 5 minutes. I told him that I had been contacted by Tania and asked him for his version of events. He told me that he just wanted to have contact with his children. I told him that the way he was conducting himself was causing some concern to Tania and Tania’s mother. I recall that he did not have much complimentary to say about Tania’s mother. During the conversation I had with Rogers he sounds quite normal and reasonable. I explained to him that if he wanted to have contact with his children and it could not be sorted out between the two parties, then he would have to go through the court process. I said that by just following Tania around while living in his car was probably not the right way of doing things. He told me that it was definitely not his intention to cause grief to Tania or her mother, he simply wanted to spend some time with his children. Rogers thanked me for the opportunity of listening to his version of events.
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It is apparent Mr Rogers was an accomplished manipulator of people and it seems he persuaded the officer he was a harmless father simply concerned about his children – a position the officer clearly had sympathy for – when the truth was quite different. Sgt Smithson then left a message for Tania Simpson confirming the details of his conversation with Mr Rogers. Mr Rogers told Ms Rizzo of his conduct on 15 February 2011 and she advised him to apologise immediately to the Simpson family. There was an apology of sorts, but one coupled with another concocted story to the effect that he was just keeping an eye on Julie Simpson while John Simpson was away. Mr Simpson, who had tolerated Mr Rogers for years despite a personal dislike of him, told the inquest that this incident caused him to make it clear in strong terms to Mr Rogers that he didn’t believe a word Mr Rogers said. It appears that Mr Rogers genuinely feared that the incident involving Julie Simpson would result in access to his children being cut off although this did not happen. There is evidence from a number of sources that, in the following weeks, Mr Rogers’ behaviour improved somewhat. He obtained part time employment (eventually working two jobs) and his health, which had noticeably deteriorated began to improve. The frequency of his text messaging and stalking type behaviour diminished. Notwithstanding, Julie Simpson told investigators that she understood Tania to have attended Broadbeach Police Station a few weeks after her call with Sgt Smithson to again speak to police. She was not aware of any further details about this visit but her understanding is corroborated to an extent by the location of domestic violence advice brochures found in Tania’s apartment after her death. Each was stamped “Broadbeach Police Station”. Inquiries with staff at the station have failed to indentify any officer who had contact with Tania and it is quite possible that she simply collected the material from the public area of the police station.

Contact with other agencies
In mid March 2011 Ms Simpson made an appointment with a psychologist as she was concerned with the anxiety exhibited by Kyla, particularly at school. That psychologist, Wendy Gollan, told the court she first saw Ms Simpson alone, as was her practice in matters relating to children, on 23 March 2011. She again saw Ms Simpson together with Kyla on 31 March 2011. Ms Gollan took a history of the relationship between Ms Simpson and Mr Rogers. She was concerned about the behaviour of Mr Rogers as it was described to her by Ms Simpson. In particular she was worried about the apparent stalking, the incident in which Mr Rogers had carved his and Kyla’s initials into a tree at her school, and his refusal to tell Tania where he was taking the children or making himself contactable when he had access. There is no suggestion of Ms Simpson overplaying the seriousness of Mr Rogers’
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behaviour; quite the opposite, Ms Gollan was in fact concerned about the lack of alarm Ms Simpson was exhibiting. Ms Gollan told investigators: I told her these behaviours were not normal, in fact they were bizarre and indicated that Paul was capable of irrational actions. I suggested that by letting the children go with him without any information about their whereabouts was placing them at considerable risk. I advised her that she needed to go through mediation to get a Parenting Plan in place so that Paul was then not legally permitted to take the children away. Ms Gollan provided details of an agency that could assist with preparing a parenting plan. It was clear to her after meeting Kyla that her anxiety was directly related to the unsettled circumstances of the relationship between Kyla’s parents. Ms Gollan organised for a follow up appointment which was not kept by Ms Simpson. Ms Gollan told the court that she understood there to be no history of physical violence in the relationship and that Tania had been in contact with police in relation to the stalking. She says that Ms Simpson did not express any fear for her own safety during the consultations. On 7 April 2011 Tania attended Relationships Australia with a view to instigating formalised mediation between her and Mr Rogers in relation to access to the children. This process is a pre-requisite to the making of an application in the Family Court for order relating to the children. Ms Simpson was seen by an experienced relationships counsellor, Libby Taylor, for an intake assessment. Ms Taylor gave evidence explaining that one part of the intake process is a risk assessment. Ms Simpson was asked “Are you intimidated by the other party? How?” In her notes of the response to that question Ms Taylor wrote: Now – Paul following Tania, Tania’s mum. Tania discussed with police – they have spoken with him. Ms Taylor did not, though, gain the impression that Tania held any fears for her personal safety or those of her children. Ms Taylor assessed the couple as being suitable for mediation. Ms Simpson was quite content for any mediation session to be conducted face to face. As per the usual procedure a letter was sent to Mr Rogers inviting him to make contact with Relationships Australia. When no reply was received a second and final letter was sent. Mr Rogers did not make any contact with the service and this entitled Ms Simpson to a certificate issued pursuant to the Family Law Act noting that the mediation session had not taken place by virtue only of Mr Rogers’ failure to engage. This certificate was issued on 9 May 2011.

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Ms Taylor told the inquest that although she was concerned by some of the behaviour of Mr Rogers described to her, she was satisfied Ms Simpson was taking a pro-active approach to addressing her own situation. In particular, she was comforted by the fact Ms Simpson had seen a psychologist for Kyla, had been in contact with police about Mr Rogers’ stalking and was now seeking to engage in mediation.

Events immediately prior to the deaths
In April 2011, Ms Simpson purchased a unit in and the management rights to the “Arbour Lane” complex at Robina. She moved in about 3 May 2011. Ms Simpson is reported to have told several witnesses that she was comforted by the security offered to her at this complex. Ominously, records found after his death indicate that on 14 April 2011 Mr Rogers purchased a set of binoculars. Ms Rizzo told the court that, after a period around March when Mr Rogers’ mental state appeared to improve, it again deteriorated in the weeks leading to his death. Ms Rizzo left the Gold Coast on 10 May 2011 to travel to Cairns with her family. She was aware that Mr Rogers was again conducting surveillance on Ms Simpson and Mr Way in a bid to “prove” they were having a relationship despite Mr Way’s denials. Ms Rizzo encouraged him to move on from the relationship with Ms Simpson and stop this kind of behaviour but it seems he took little notice. On 8 and 9 May 2011 Mr Rogers rented vehicles from Gold Coast Family Car Rentals. Also on 8 May he hired another vehicle, a white Proton sedan from Kanga Car & Moped Hire (“Kanga”) until 12 May 2011. As he had a perfectly serviceable vehicle, it may be presumed he did this so that Tania and her family and/or Mr Way would not recognise him in another car if he was following them On returning the vehicle Mr Rogers was told that Kanga staff had received a call from a person concerned that the vehicle had been left parked for an extended period in one spot and may be stolen. This appeared to alarm Mr Rogers who wanted to know if any of his personal details had been given out. On 11 May 2011 Tania Simpson reported to police that a glass entry door to the unit complex had been smashed and levered open allowing access to an underground secure garage. The remote security garage electronic box was opened and some of the internal wiring was ripped out rendering it inoperable. Mr Simpson told the inquest that he arranged for the box to be repaired the following day. No fingerprints were found and no person ever identified as being responsible. At the inquest, the investigating officer, Detective James told the inquest that she suspected this offence had been committed by Mr Rogers. His motive for doing so would have been to familiarise himself with methods of accessing the complex and, in particular, the door to Ms Simpson’s apartment. He also possibly hoped the garage door would not be repaired so quickly, allowing him a further entry point.
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Ironically, on the same day, Ms Rizzo sent Mr Rogers a text message saying among other things; “No stalking.” She explained she did this because she was concerned that Mr Rogers was obsessing about the possibility of Ms Simpson and Mr Way being romantically involved. On 12 May 2011 Mr Rogers telephoned Ms Rizzo to triumphantly proclaim that he had finally “proven” that Ms Simpson and Mr Way were seeing each other. He told Ms Rizzo he had observed Mr Way come and go from Ms Simpson’s flat. Ms Rizzo told the court that there was no discussion about what he intended to do now he had this information. Also on 14 May he rang the mother of Mr Way’s former partner and pretended to be a friend of her daughter’s in an effort to obtain her contact details, presumably to check on Mr Way’s whereabouts.

The killing of Antony Way and Tania Rogers
All of the people who witnessed or might have witnessed events within the apartment of Ms Simpson on the evening of 14 May 2011 are now deceased. At the inquest the investigating officer posited a likely scenario of events which is supported by the extensive forensic evidence and I accept is likely to be correct. Detective James told the inquest that Mr Rogers, as on previous days, likely took up a position to conduct surveillance on Ms Simpson’s unit complex. His intentions were already well formed though because he had earlier removed a hose from the washing machine at Ms Rizzo’s residence and packed this into the car along with towels, a knife and gaffer tape. Shortly after 9:30pm Mr Rogers would have seen Mr Way’s car enter the complex. After waiting for another car to enter or exit the secure car park he was able to enter the car park. The car park is blocked from the internal stairway by a door that only requires a key in order to access the car park from the stairwell, but not the other way. Perhaps to keep his options open, Mr Rogers disabled the locking mechanism on the internal door with gaffer tape (although he did not ultimately return via this door). He was then able to make his way freely to the front door of Ms Simpson’s apartment. Examination of the door by showed no signs of forced entry meaning Mr Rogers was able to talk his way in or that the door had not been locked after Mr Way entered a short time earlier. It seems likely Mr Way was attacked first and without warning. He was found lying partly inside the bathroom that entrance to which is immediately outside Kyla’s room. He was still wearing all the clothes he had entered in and had only dropped a day pack inside the front entrance way. No significant defensive injuries were observed at autopsy and he likely fell to the ground at the spot he had been stabbed. Mr Way was stabbed five times with two of the wounds being fatal wounds. All were to the right side of the torso. It is likely that only one or two of these wounds were inflicted in the initial assault.
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Blood from Mr Way was found on the arch of Tania Simpson’s foot indicating she was near-by when Mr Way was killed. It is likely that Ms Simpson ran from this point to the kitchen and attempted to grab her mobile phone and car keys. The phone was still attached to a recharger and forensic analysis of the power socket shows that considerable force was used to remove it from the wall. The forensic evidence supports the contention of Detective James that Ms Simpson was then attacked from behind and that Mr Rogers initially attempted to cut her throat. Two cuts to the throat observed at autopsy were not considered to be fatal wounds. As she continued to try and get away from him, blood from those wounds has spurted along the kitchen bench. In a frenzied attack Mr Rogers then stabbed Ms Simpson multiple times. Including the cuts to the throat and a number of self defence wounds, she was reported to have 31 injuries inflicted by a bladed weapon. It is likely that Mr Rogers then returned to the body of Mr Way and stabbed him a further three or four times. It would have been necessary for Mr Rogers to walk over the body in order to gain access to Kyla’s bedroom. Analysis of blood staining patters on a pillow found nearby indicated that it had been on top of Mr Way at one point after the initial attack but was later moved. Another pillow remained on top of Mr Way. Blood staining on the doona of Kyla’s bed is consistent with Mr Rogers having pulled it back before he scooped up Kyla. Between 9:30pm and 10:00pm the residents of a unit on the floor above Tania’s heard screams and a woman pleading: “No, no, no, please no.” which likely corresponded with Ms Simpson’s reaction to the stabbing of Mr Way. Two of them went out of their doorway and looked down the stairwell. They saw and heard nothing. A few minutes later they again looked out and on this occasion they heard a door from the unit below open, and saw a man carrying a young child emerge. One of those observers recognised the other man as the father of Tania’s children. He was heard to say words to the effect, “You can come and stay with daddy tonight.” Another of the observers recalled hearing the man say “Shhh, Daddy is here”. Police also received an eye witness account of a male driving away in a white or light four door vehicle. None of these witnesses made contact with police that evening.

Discovery of the deaths
John Simpson arrived at his daughter’s unit complex around 8:00am the following day, Monday 16 May 2011, to help her with cleaning and maintenance of the complex. After attending to some of this he buzzwed Tania’s apartment and received no reply. He had seen a car he knew belonged to Mr Way in the car park. He made several attempts to telephone his daughter before eventually using his key to enter. He discovered the body of Mr Way in the hallway and, understandably shaken, did not notice the body
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of Ms Simpson as he returned to the front door. At 8:16am he telephoned Broadbeach police communications to report the death and to tell them both his daughter and grand daughter were missing. Senior Constable Paul White was the first officer on the scene. He arrived at 8:23am and conducted a video taped inspection of the apartment. He found the body of Ms Simpson and relayed this information to his supervisors. Senior police and CIB investigators arrived at the scene between 8:49am and 9:20am. A detailed forensic examination of the scene commenced. A statement was taken from Mr Simpson who immediately nominated Paul Rogers as the likely suspect. Investigators set about confirming details of the deceased, of the known and possible missing and of all vehicles that might be relevant to locating them.

The search
At 9:00am a broadcast was issued to all police in the Gold Coast and Coomera districts to be on the lookout for Mr Rogers and Kyla in Mr Roger’s Silver Holden Viva wagon. A similar message was broadcast via the NSW police radio communications system at 9:28am in the form of a “Keep a lookout for” or “KLO4” broadcast. This message included the further information that Mr Rogers may be armed and that grave concerns were held for the welfare of Kyla Rogers. The inquest heard from NSW Police Inspector William McKenna that on 16 May 2011 he was the Duty Officer for the Richmond Local Area Command, an area that covers a large portion of north-east NSW and includes the towns of Ballina, Lismore Kyogle and Casino amongst many others. He told the inquest that further details from Queensland police indicated Mr Rogers may be in the Kyogle or Casino areas. He travelled to Casino with a colleague where he met up with another officer he had stationed to watch passing traffic on the main thoroughfare. A further KLO4 broadcast was issued at 10:39am informing police that a mobile telephone “triangulation” had been conducted and Mr Roger’s phone had been detected in the Kyogle and Casino areas. At 12:05pm and again at 12:08pm a radio broadcast was received giving precise details of the purported location of Mr Rogers’ mobile phone. The grid co-ordinates obtained allowed the location to be confined to Shepherd’s Lane, a single dead end road, approximately 10 kilometres north of Casino. At the same time Inspector McKenna had two further pieces of information conveyed to him, namely: • That the mobile telephone had not moved since 9:30am (although at the inquest Inspector McKenna noted that even this information was open to doubt as the phone kept receiving signals from different towers through the course of the day); and 15

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That Mr Rogers could possibly be driving a white Toyota utility vehicle.

Inspector McKenna travelled to a location near Shepherd’s Land and coordinated a large contingent of police with the aim of identifying whether Mr Rogers and/or Kyla were in the area. If Mr Rogers was found it was the Inspector’s intention to contain him in the area while seeking assistance from the State Protection Support Unit (SPSU). At this time police negotiators in Queensland and NSW had already been briefed. A white utility was located and placed under surveillance. After an hour or so it was established the utility was not carrying Mr Rogers. Just before 2pm Inspector McKenna spoke to the Duty Operations Inspector. who told him the coordinates supplied earlier were mistaken, relating as they did, to the location of a possible tower rather than the location of Mr Rogers’ phone. The most accurate triangulation information available could only narrow the possible location of Mr Rogers’ phone to an area with a radius of more than 50km around Casino. Inspector McKenna instructed all police to stand down and return to Casino police station. At 2:51pm he debriefed all personnel at the station. Officers were instructed to continue an active look out for the subject vehicle. Inspector McKenna then sought an update on considerations by Queensland police on whether to call the phone of Mr Rogers. Consideration of this had been put off while the situation in Shepherd’s lane was being investigated. It was agreed the mobile phone of Mr Rogers should be called and a surrender plan was devised to discuss with him should the call be successful. Two calls to the phone went to a message service. Inspector McKenna returned to his station at Lismore where he examined the call charge record that had recently been obtained for Mr Rogers’ phone. That showed there had been no activity since at least 7:05am. Queensland police had by this time added two further vehicles to the list of vehicles of interest, namely Ms Simpson’s black Ford Mondeo and her former vehicle, a black Ford Territory. Further attempts at triangulation through the afternoon had failed to narrow the search area. Inspector McKenna finished his shift at 5:30pm leaving instructions to be called should vehicles or persons of interest be located. At 3:33pm Queensland Police issued a Child Abduction Alert resulting in the broadcast of identifying particulars of Paul and Kyla Rogers and the Holden station wagon that Mr Rogers was suspected of driving. Child Abduction Alerts result in the broadcast of this information via electronic motorway signs, radio and television broadcasts, email and social media. Consideration had been given to issuing such an alert on at least two occasions on the morning after the bodies of Ms Simpson and Mr Way had been discovered but senior police had determined they did not have the reliable information that guidelines on the issuing of these alerts require. Subsequently, it appears that further consideration was delayed while the events at Shepherd’s Lane played out the prospect of imminent negotiations with Mr Rogers were very real.
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Rogers and Kyla are found
At 5:00pm on 16 May, a school bus driver was returning home after the afternoon run was driving along the Bruxner Highway when he saw a silver station wagon parked in bushland just to the south of the roadway about 15km west of Casino near an area know as Piora Bridge. At the time he thought nothing of it. Later, when he saw an item on the 6:00pm television news, the significance of what he had seen became apparent and he contacted NSW police who sent a crew to the scene. 1 On arrival, those officers positively identified the vehicle as that of Mr Rogers, but, unable to see inside and with the warnings about Mr Rogers possibly being armed, they advised police communications and stood back and waited for support. At 7:45pm Inspector McKenna was contacted at home and travelled to the scene. He arrived at 9:22pm and decided to approach the vehicle as there had been no sign of movement since police arrived. As he walked towards the vehicle he observed tyre tracks suggesting the vehicle had performed a three point turn and then reversed into a disused bush driveway that leads to a boundary fence. He shone his torch into the vehicle and saw a male we now know was Mr Rogers lying in a reclined position in the driver’s seat with a large amount of grey coloured tape wrapped around the lower part of his head. He then saw Kyla Rogers lying on the right hand side of the man’s chest and torso. The doors were locked and he instructed an officer to gain entry using an axe. That officer then checked for any vital signs. It was immediately clear that both people were deceased and had been so for many hours.

The investigation findings
Analysis of CCTV footage from the Tugan bypass tunnel showed the Holden Viva station wagon driven by Mr Rogers passing through at 10:27pm. This is the last positive sighting of the vehicle or of either of the occupants prior to their deaths. Analysis of Mr Rogers’ mobile telephone records show that he telephoned his mother in New Zealand three minutes after passing through the Tugan bypass tunnel. This call went through to an answering service (being the early ours of the following morning in New Zealand). Nothing discernable could be heard on the message. At 3:16am a call was made to the NSW emergency number “112”. An audio tape of this call was tendered at the inquest but does not contain any audible words. This call went via a cell tower at Parrot’s Nest in NSW. If Mr Rogers had driven uninterrupted to his final destination he would have arrived prior to this call being made. I consider that was the likely scenario.

1

NSW Police later received another credible eye witness account from a motorist on the Bruxner Highway, after the bodies had been located, that he had seen the silver station wagon in the same location at 7:30am on 16 May 2011. This is the earliest sighting of it in that location.

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Two other text messages received by the phone of Mr Rogers shortly after 7:00am were found to be from Mr Rogers’ employer. A washing machine hose found on the ground next to the car when it was located near Piora Bridge was identified as having been taken from Ms Rizzo’s unit. Pieces of tape attached to the boot and rear window and the hose lead to the conclusion that at some stage exhaust gas had been fed into the passenger compartment of the car using the hose. A QPS forensic officer examined the pieces of tape found at Robina and Piora Bridge. She determined that one end of the tape found in the stairwell garage access doorway at Ms Simpson’s apartment complex formed a complimentary fit to one end of a small piece of tape attached to the length of hose found near Mr Roger’s vehicle in NSW. A QPS fingerprint expert positively identified fingerprints belonging to Paul Rogers in various locations in and around Ms Simpson’s apartment and the unit complex, including on the handle of the bloodied knife located in Kyla’s bedroom. Blood samples taken from the tip of this knife were tested and resulted in a mixed DNA profile. The major contributor to this profile was Tania Simpson; an incomplete minor contributor belonged to Antony Way.

The autopsies
Post Mortem examinations on the bodies of Tania Simpson and Antony Way were conducted by Dr Dianne Little, an experienced forensic pathologist, at the Gold Coast Hospital on 17 May 2011. In her examination of Tania Simpson, Dr Little noted the following significant injuries: • • • • 2 cuts to the throat which damaged muscle without severing blood vessels; 9 stab wounds about the torso including the fatal wound (see below); 6 defence wounds between the elbow and wrists of the right arm 6 defence wounds to the right hand including 1 entering and exiting

She concluded that the fatal wound was a 12cm deep stab wound through the right anterior chest which was 45mm in length at the surface and which cut into the bronchus (air passage) and the adjacent blood vessel. This would have caused both lungs to fill with blood. This particular wound would have required significant force as it cut through one of the ribs. Dr Little later issued an autopsy certificate listing the cause of Ms Simpson’s death as: 1.(a) Stab wound to chest In her examination of Antony Way, Dr Little noted 5 stab wounds on the right hand side of the torso including two fatal wounds.
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She concluded that the fatal wounds were: A 14.4cm deep stab wound (34mm in length at the surface) on a 45 degree downward direction commencing on the upper right chest. This extended through the right atrium and severed the right lung. Dr Little concluded that it caused extensive bleeding into the chest cavity. Another stab wound of unknown depth (35mm in length at the surface) to the base of the neck severed the jugular vein. This would have caused fatal exsanguinations in a very short period of time. Dr Little later issued an autopsy certificate listing the cause of Ms Simpson’s death as: 1.(a) Stab wounds to neck and trunk Post Mortem examinations on the bodies of Kyla and Paul Rogers were conducted by Dr Little at the Gold Coast Hospital on 18 May 2011. In her examination of Kyla Rogers, Dr Little saw no signs of internal injuries. She noted bruising to the ribs consistent with being held closely with some force. There were also petechial haemorrhages over the head, neck, upper arms and upper trunk. Examination of the brain revealed mild swelling of the and, under microscope, petechial haemorrhages. These signs are consistent with hypoxia (lack of oxygen to the brain). There were no signs of strangulation. Colouring of the chest cavity blood was consistent with carbon monoxide poisoning but toxicological testing established that this was not the cause of death. Dr Little concluded: “Petechial haemorrhages can be seen in asphyxial deaths. Their limitation to her upper body in this case is suggestive that there may have been compression of her chest which impeded respiration and caused her death.” Dr Little issued an autopsy certificate listing the cause of death as: 1.(a) Asphyxia In her examination of Paul Rogers, Dr Little observed a number of superficial external injuries. The chest cavity blood exhibited a colour consistent with carbon monoxide poisoning, but again this was not the cause of death. Asphyxiation as a cause of death could not be conclusively established from the autopsy examination alone. In circumstances where other causes of death were ruled out and Dr Little concluded the tape over Mr Rogers mouth and nose would have made it impossible to breath she was satisfied that asphyxia via smothering was the cause of death. Death would have been hastened by significant narrowing of one of the coronary arteries, causing a fatal arrhythmia earlier than would have otherwise been the case.
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Dr Little issued an autopsy certificate listing the cause of death as: 1.(a) Smothering (occlusion of external airways by duct tape) As mentioned, toxicological testing showed that, while both occupants of the vehicle were affected by carbon monoxide, it had not built up to fatal levels. Investigators later made contact with the vehicle manufacturer and conducted their own testing to determine likely time frames for the fatal build up of the gas. It seems clear that at some stage the hose was connected to the exhaust outlet and the passenger compartment. Perhaps because he feared discovery, or for some other reason, Mr Rogers removed the hose from the vehicle before it had fatal effect. It is likely he then asphyxiated Kyla, who may have already been unconscious, by holding her forcefully against his chest. Mr Rogers then wrapped the remaining gaffer tape tightly around his mouth and nose blocking his airways and causing him to suffocate. It is likely that Paul Rogers and Kyla Rogers died before the bodies of Antony Way and Tania Simpson were found shortly after 8:00am.

Findings required by s45
I am required to find, as far as is possible, who the deceased people were, how they died, when and where they died and what caused their deaths. As a result of considering all of the material contained in the exhibits and the evidence given by the witnesses, the material parts of which I have summarised above, I am able to make the following findings. Identity of the deceased The deceased people were: Antony Paul Way Tania Lee Simpson Kyla Anne Rogers Paul Anthony Rogers Mr Way and Ms Simpson died as a result of being repeatedly stabbed by Mr Rogers after he gained entry to the residence of Ms Simpson. He then abducted his daughter Kyla from the residence, and drove to northern New South Wales. There he asphyxiated Kyla before killing himself. Antony Way and Tania Simpson died at Robina in Queensland. Kyla Rogers and Paul Rogers died at Piora, via Casino in New South Wales. Mr Way and Ms Simpson died on 15 May 2011. 20

How they died -

Place of death -

Date of death -

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Mr Rogers and Kyla Rogers died on 16 May 2011 Cause of death Antony Way died as a result of stab wounds to the neck and trunk. Tania Simpson died as a result of a stab wound to the chest. Kyla Rogers died from asphyxia. Paul Rogers died from the smothering of external airways.

Concerns, comments and recommendations
Section 46, in so far as it is relevant to this matter, provides that a coroner may comment on anything connected with a death that relates to public health or safety, the administration of justice or ways to prevent deaths from happening in similar circumstances in the future. The circumstances of this case raise several issues which warrant consideration from that perspective, namely:• • • • Whether there were missed opportunities for the police or other welfare agencies to intervene; Should a child abduction alert have been broadcast sooner; Are current QPS policies and training concerning the response to domestic and family violence optimal; and Are any other change to public policy warranted

The connection between domestic violence and homicide
Before turning to those issues it is appropriate to set the scene by summarising the research evidence that was presented to the inquest concerning the connection between domestic and family violence and homicide. It is against this background that the importance of effective intervention in potentially fatally infected relationships can be starkly illustrated. Law enforcement and human services practitioners have long been aware that a significant proportion of homicides could also be characterised as extreme incidents of domestic violence. However, the scope of the calamity and how it could be reduced have received scant attention from coroners and homicide detectives. Traditionally, if the perpetrator survived the incident, he/she was prosecuted and the file closed. If the perpetrator also took his/her own life, little if anything was done. The creation of the Domestic and Family Violence Death Review Unit (DFVDRU) in the Office of the State Coroner (OSC) in 2011 was an attempt to do more; to learn from these terrible events with a view to reducing their incidence.
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Scale of the problem
Although the unit has been in operation for less than 12 months it has already made significant contributions to our understanding of this terrible social problem. For example, prior to the unit analysing all suspected homicides reported in Queensland in the last six years, we were not even aware of the magnitude of the problem. As the table below shows, 47% of homicides that occurred between 2006 and 2011 involved domestic or family violence; that is, the killer was, or had been in an intimate relationship with the deceased or was or had been a member of the deceased person’s family. This is not a factor unique to Queensland: Between 2007 and 2008 there were 273 homicides in Australia. Over half, 144 or 53%, were killed by a person with whom they shared a current or former domestic/family relationship (National Homicide Monitoring Program, Australian Institute of Criminology, Annual Report 2010).

Total Number of Homicide victims in Queensland 2006 2007 2008 2009 2010 2011 Total 59 52 55 53 45 44 308

Total number of DFV homicide deceased persons in Queensland 34 23 27 17 18 25 144

Percentage

58% 44% 49% 32% 40% 57% 47%

A review of the relevant research literate demonstrated numerous factors associated with an increased risk of homicide were richly represented in the factual circumstances of this case.

The characteristics of deadly relationships
Dr Michelle Hayes, the senior researcher attached to the DFVDRU, compiled a report analysing this incident in the context of research relating to the link between domestic violence and homicide. Dr Hayes told the court she had analysed statistics compiled by the Ontario Domestic Violence Death Review Committee. A dearth of Australian statistics relating to links between domestic violence and homicide (particularly cases of murder/suicide) meant that the highly regarded Ontario studies were the best source of information. That allowed her to identify the 12 risk factors most commonly present in domestic and family violence homicides. Dr Hayes told the court that 9 of these risk factors were present in the circumstances of this case. They were: 1. Actual or pending separation;
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2. Obsessive behaviour displayed by perpetrator (i.e., stalking); 3. Perpetrator depressed in the opinions of professional and/or nonprofessionals (i.e., family, friends); 4. Victim had intuitive sense of fear; 5. Prior threats/attempts to commit suicide; 6. Prior threats to kill victim; 7. Perpetrator unemployed; 8. Prior attempts to isolate the victim; and 9. An actual or perceived new partner in victim’s life. The most dangerous time for victims is at or soon after separation. Extremely controlling perpetrators are particularly dangerous under conditions of estrangement. This is explained further in the conclusions of other studies cited by Dr Hayes. Social work lecturer Carolyn Harris-Johnson conducted a 10 year study of men who kill members of their family. She drew the following conclusions: My research showed that where these cases had occurred, there wasn’t actually an existing dispute in the courts, so what I see is that the proprietary attitude that these men have, both towards their wives and towards their children, allows them to commit the offence, because they are possessions of his, they’re not entities in their own right… We are talking about a very, very small group of men who have a particular and intense need to control their partner and who will never accept the finality of separation… Things like veiled threats to harm the children or explicit threats to harm the children or the self should be warning flags to everyone. She has also reported: Intimate partner murder-suicide often occurs when a threat to the insecurely attached male is experienced most intensely, when he perceives there is no chance of reconciliation or return to the love object. Up until that point, even though a physical separation may have occurred, he may be able to harbour a view that reconciliation is possible. There remains some hope of return to the proximity of the love object. This leads to the issue of stalking… which may be conceptualised as a pathological need for omnipotent control of the other…. Dr Hayes noted in her report there is further, independent, research to support the link between a proprietary attitude by a male towards his family, and subsequent incidence of familial homicide. Counter intuitively perhaps, the evidence does not indicate it is usual to observe an escalation of the severity of domestic violence from non violent abuse through increasingly violent action to homicide. According to Dr Hayes the research data indicates homicide is just as likely to arise in circumstances where there has been no history of serious physical violence, especially
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during the breakdown phase of a relationship where the party who has not initiated the separation is very controlling and un-accepting of it. This analysis highlights many of the characteristics of the context in which these deaths occurred. Mr Rogers, although not physically violent to Ms Simpson, was very controlling throughout their relationship. He sought to isolate Ms Simpson from friends and family. He refused to accept their separation and went to bizarre lengths to maintain knowledge of her movements and associations. He continually tried to force her to resume the relationship manipulating the children to this end. When it became clear there were no prospects of his regaining the dominance he craved, his life to him became meaningless and he took the most severe revenge; he exercised the ultimate act of abusive control by killing her and her child.

Opportunities for intervention in this case
QPS D&FV policies in February 2011
Section 19.6.1 of the QPS Operational Procedures Manual (OPM) sets out QPS policy on how police are to respond to circumstances of domestic violence. Using terminology from the Domestic and Family Violence Protection Act 1989 (DFVPA) the OPM requires: An officer who reasonably suspects a person is an aggrieved is to investigate or cause to be investigated, the complaint, report or circumstance, on which the officer’s reasonable suspicion is based, in accordance with s.67(1) of the Act” 2 An aggrieved is a person for whose benefit a domestic violence order may be sought. So far as is relevant, domestic violence is defined in the Act to include “intimidation or harassment of the other person” 3 Examples given immediately below this part of the definition include: 1. following an estranged spouse when the spouse is out in public, either by car or on foot 2. positioning oneself outside a relative’s residence or place of work Once an officer suspects a person is an aggrieved under the DVFPA the OPM states that an officer should interview the aggrieved, the respondent and any witnesses to the acts which form the basis of the suspicion.

Were they complied with?
On 16 February, the day after Mr Rogers had been caught following Tania’s mother, she rang the Broadbeach Police Station and complained to Sergeant Smithson about the actions of her estranged partner. The telephone call lasted for 18 minutes.
2

Section 67(1) imposes a requirement on officers investigating a matter to continue the investigation until they are satisfied that their reasonable suspicion that a person is an aggrieved is unfounded. 3 S.11(1)(c) DFVPA
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Sgt Smithson is the only person who now knows the extent to which Ms Simpson disclosed details of Mr Rogers’ behaviour. The timing of the call suggests details of the incident the day before would have been disclosed. Although Sgt Smithson could not recall this information specifically it is consistent with his recollection that Tania was more concerned about her mother than herself. Sgt Smithson agreed he was aware Mr Rogers was following Ms Simpson and that this was being done with a view to improving Mr Rogers’ prospects of seeing his children. Sgt Smithson told the inquest that he had not formed a suspicion that Ms Simpson was an aggrieved as he did not consider the acts complained of constituted domestic violence. I accept his evidence that he would have explained the definition of domestic violence; the possibility of an application being made for a domestic violence order; how such orders work; and what conditions they might contain. I am of the view that the information disclosed to the officer could have given rise to a reasonable suspicion that Tania Simpson was an “aggrieved” within the terms of the Act or at least ought to have prompted further questioning about Mr Rogers’ behaviour that is likely to have done so. Accordingly, it could be argued that Sgt Smithson’s failure to conduct further investigations constituted a breach of the OPMs. However, I am mindful that Sgt Smithson was clearly acting in good faith and took concrete steps to address Ms Simpson’s concerns. With Ms Simpson’s agreement, he rang Mr Rogers and encouraged him to desist. As is apparent from his manipulation of many others, Mr Rogers was adept at disguising his real intentions and duped the officer into believing he was an innocuous father simply wishing to spend more time with his children. I am mindful that I am analysing the approach adopted by Sgt Smithson with the knowledge of what occurred to Ms Simpson and Mr Rogers three months later. It would be unsound to conclude that had a DVO been obtained in February 2011, the murderous dynamic that unravelled in May would necessarily have been avoided. In my view it would be unfair for Sgt Smithson to face any action in connection to his performance on 16 February. I have no doubt his involvement in this case will have far greater formative effect than any other action that could be taken.

Lawyer’s response
On 15 December 2010 Ms Simpson attended Sempre Vero Lawyers at Miami for an initial consultation regarding her separation from Paul. Julie Falcke, a
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lawyer at Sempre Vero assisted Ms Simpson in finalising a formal property settlement that was agreed to by Mr Rogers on 23 February 2011. Ms Simpson disclosed to Ms Falcke that Mr Rogers had initially wanted to see the children every day and when told it was impractical he had put a razor across his chest. She told Ms Falcke that she thought Mr Rogers might be “emotionally unstable”. As a result Ms Falcke advised Ms Simpson that any time Mr Rogers spent with the children should be supervised and advised her of the process required for obtaining Family Court Orders to this effect. Ms Falcke discussed the need for mediation and provided details for Relationships Australia. Tania told her that she did not wish to seek Orders in relation to the children at that time. I am satisfied that Ms Falcke provided an appropriate level of advice and support for Ms Simpson in light of the disclosures made.

The psychologist’s response
Earlier in these findings I set out the details of Ms Simpson’s contact with Ms Gollan. I noted that Ms Gollan was aware police had been contacted in relation to Mr Rogers’ stalking and that there was no history of physical violence in the relationship. She arranged a further appointment for Ms Simpson and Kyla and left a message when Ms Simpson did not turn up at the scheduled time. In the circumstances I am satisfied that the clear warning she gave Ms Simpson about the potential seriousness of Mr Roger’s behaviour was an adequate response.

Relationship Australia’s response
I also dealt with the contact between Ms Taylor and Ms Simpson. For similar reasons as with Ms Gollan (ie knowledge of police involvement and no history of violence) and because Ms Simpson expressed no concerns over engaging with Mr Rogers in a face to face mediation, I do not consider it was incumbent on Ms Taylor to have done any more.

Child abduction alert
QPS policy on child abduction alert
The QPS OPM sets out strict requirements for first response officers in relation to what information is to be collated and then passed on to senior officers in cases of alleged child abductions. The OPM requires the Regional Duty Officer decide whether or not an alert is to be implemented. It then sets out the series of actions required to ensure that alert is properly disseminated. The OPM is not prescriptive in terms of stating when a child abduction alert must or must not be issued once these three criteria are met:

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1. There are reasonable grounds for believing that a missing child under the age of 17 has been abducted; 2. The child is at risk of serious harm or death; and 3. There is sufficient descriptive information available to make an alert effective.

Were the policies complied with
I accept the evidence of Inspector McKenna and Sergeant Dalton that in this case the Child Abduction Alert was considered at an appropriately early juncture but not issued until later in the day because: 1. Investigators did not have sufficient confidence about which vehicle Mr Rogers was driving; 2. Investigators were waiting for the outcome of the situation that developed in Shepherd’s Lane; and 3. It was first necessary to make attempts to call Mr Rogers in order to begin possible negotiations with him and this process too needed to wait on the outcome of the situation in Shepherd’s Lane. I am not convinced that some of the other reasons cited such as the broadness of the area identified by triangulation were good reasons to withhold an alert, however, in light of the above, though, I do not find any breach of the QPS policy.

Current QPS D&FV policies
The Domestic and Family Violence Protection Act 2012 comes into effect later this year. One feature of that Act which will hopefully assist with the issues identified above is the widened definition of “domestic violence” which now specifically incorporates a number of non-violent type behaviours. In preparation for the implementation of this Act the QPS engaged a psychologist who, together with the QPS Domestic and Family Violence Unit devised the QPS Domestic Violence Protective Assessment Framework. This is a non-prescriptive tool that is designed to assist operational officers in determining how to respond to complaints, reports or circumstances of domestic violence. Inspector Chris Stream from the unit gave evidence at the inquest. The Framework intended to be used by officers includes a list of 22 risk factors divided into two categories. The first category of 10 risk factors is meant to represent those which are risk indicators for serious injury or homicide. The second category of 12 risk factors represents those which are pointers to further, presumably less serious, domestic violence. The latter 12 risk factors include: “4. Controlling Behaviour: does the respondent try to control the aggrieved, for example where he/she goes, what they do, who they spend time with, controlling finances, isolating the aggrieved from friends, family and/or support?;
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. . 10. Stalking: does the respondent follow, contact, intimidate, place under surveillance, manipulate or harass the aggrieved?” The evidence placed before me in this inquest indicates that these two risk factors, at least when combined with circumstances of relationship breakdown are particularly concerning and should perhaps belong in category one of the QPS Framework. I shall refer to this further below. The framework is said to employ “a structured professional judgment approach.” I can readily appreciate that there are so many factors relevant to an assessment of risk in a potentially violent domestic situation that being prescriptive could be counter productive. Conversely, having carefully read the handbook, designed among other things to provide first response officers with “greater guidance to identify the person most in need of protection”, I was left in some doubt as to whether it was likely to achieve that.

Is further reform necessary?
Reliance on a police response is unlikely to be entirely effective having regard to the evidence indicating deadly domestic violence may not be preceded by physical violence. The qualitative dysfunction exhibited by controlling manipulative parties is not conducive to detection and prosecution in the same way physically violent crimes. Increased public awareness of the dangers of controlling behaviour and stalking where relationships have recently come to an end might empower friends, family and colleagues to take steps they might not otherwise on the basis that it is “none of their business”. Dr Hayes told the inquest of the excellent work that has been conducted and under the “Act as 1” program devised and implemented by the Department of Communities. I suggest later that it be continued.

Conclusions and recommendations
I accept that Tania’s family and many friends were supportive and cared for her welfare. They did all that they could to make her and her children safe. I also accept that the lawyers, counsellors and police officers she had contact with took reasonable steps to advise her of her options. Having regard to what they individually knew, none of them could reasonably have been expected to do more. They gave advice about possible legal responses to her ex-partner’s peculiar, concerning behaviour which quite properly included mediation, counselling and applying for a domestic violence order. Everyone who knew about Tania’s situation and Paul Rogers’ bizarre actions was concerned, but none foresaw such a terrible conclusion to the breakdown of their relationship. Even experts in the field did not accurately assess the danger Mr Rogers posed to his ex-partner and their children.

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In those circumstances, it is tempting to say that nothing could have been done, but in my view that is not good enough. This was not an isolated case. As the figures quoted earlier show, on average, over the last six years, 24 people have died in Queensland every year as a result of domestic and family violence. Nearly half of all homicides committed during that period involve domestic or family violence. There is no reason to believe that this terrible toll will diminish if we simply continue to do what we have been doing – more families will suffer the agonising loss of children, grandchildren, parents and siblings dying at the hands of those who should be their fiercest protectors. The community will continue to pay a huge financial price: domestic violence was estimated to cost the Australian economy $13.6 billion in 2009. It was extrapolated that without appropriate action to address the problem, the cost will rise to $15.6 billion per annum by 2021. 4 The emotional cost and the psychological damage done to the orphans and other survivors of domestic violence deaths is inestimable. We know that in this case 21 people were aware of factors that when aggregated and analysed with expert insight indicated Paul Rogers was manifesting most of the indicators associated with deadly domestic violence. He was controlling and manipulative; he was obsessive and dishonest; he had previously threatened to kill Tania and take the children. He was stalking her and her family and she intuitively knew he was capable of harming her. He broke into her premises. He bought binoculars to spy on her. At the end he was confronted with evidence indicating his chances of regaining control of Tania were gone. A more broadly focussed wide ranging inquiry into the family’s circumstances could have revealed all or most of this. Intervention that focused on containing Mr Rogers until his destructive psychopathology could be ameliorated or minimised may have saved them all. Those charged with helping the family stay safe did not have processes that gathered the necessary information, nor the expertise to adequately interpret it. This is not a criticism of the QPS, the frontline agency responding to this social scourge. I am readily persuaded it is committed to doing all that it can to address domestic and family violence that imposes a huge burden on its resources – approximately 50,000 calls for service each year. It has a specialist group, the Domestic and Family Violence Unit (DFVU) within the Operations Support Command that continually reviews relevant QPS policy, procedures and training. That unit coordinates the implementation of reduction strategies across the state via a network of 25 District Domestic and Family Violence Coordinators. The work of that unit is essential to on-going improvement among first response officers and must continue. However I am convinced a small, expert, interdisciplinary unit focussed on the worst cases – those resulting in death - is needed to augment the work done
The Cost of Violence Against Women and their Children', The Department of Families, Housing, Community Services and Indigenous Affairs, Canberra, Australia, 2009
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by the QPS DFVU. Such a unit already exists – the Domestic and Family Violence Death Review Unit (DFVDRU). The DFVDRU aligns with the National Plan to Reduce Violence Against Women and their Children 2010-2022 which mandates states and territories drive continuous improvement through sharing outcomes of reviews into deaths and homicides related to domestic violence. It was implemented in early 2011 when the Department of Communities, Department of Justice and Attorney-General and the Queensland Police Service each funded the necessary positions - a manager of the unit, a research assistant and a detective. The purpose of the DFVDRU is to identify and intensively review each domestic and family violence related death in order to gain an understanding of the context and circumstances in which these deaths occur to identify changes that may reduce them. The DFVDRU is part of a national network, comprising domestic violence death review units from NSW, Victoria, South Australia, and Western Australia. The Unit is to be reviewed in mid 2012, with a decision to be made by the Minister for Community Services about whether to continue its function. I readily acknowledge there are always competing claims for public funds and that it is the responsibility of government to balance these demands. However, I am persuaded by the valuable contribution made by the unit’s analysis of these deaths and other reports that I have read that will inform future inquests that its disbanding would be a set back for community safety.

Recommendation 1 – Continuation of the DFVDRU
Having regard to the number and proportion of homicides associated with domestic and family violence and the limitations of current policing and intervention models to prevent them, I recommend the Departments of Communities, Justice and Attorney General and Police continue to fund the Domestic and Family Violence Death Review Unit so that intensive, expert scrutiny of all aspects of these deaths can better inform the responses of the relevant agencies. I have earlier described the QPS Domestic Violence Protective Assessment Framework. It is a very worthy initiative but the evidence presented to this inquest suggests some of its categorisation of risk factors should be reviewed. I have also drawn attention to doubts about its effectiveness as a screening tool.

Recommendation 2 - DV Protective Assessment Framework.
I recommend that officers of the QPS DFVU liaise with the officers of the OSC DFVDRU to review the categorisation of some of the risk factors contained in the protective risk assessment framework and that they apply the assessment tool to the circumstances of the domestic and family fatalities reviewed by the
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DFRU to ascertain whether it is likely to have prompted first response officers to have effectively intervened. Finally, I am of the view the evidence presented to this inquest could be utilized by officers engaged in the Act as 1 program administered by the Department of Communities to raise public awareness of the perniciousness of non violent domestic violence.

Recommendation 3 – Don’t wait for physical violence
I recommend the officers of the OSC DFVDRU liaise with the Department of Communities to consider whether the evidence presented to this inquest should inform public awareness campaigns about the risks posed by non violent domestic and family violence. I close the inquest. Michael Barnes State Coroner Southport 21 June 2012

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