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A CORONER has found that a mental health service who closed their file on Derrinallum bomber Glenn Sanders was a “missed opportunity”.
There were also questions raised why when the file was closed by Camperdown Community Mental Health Services that Mr Sanders’ doctor and local police were not informed.
They were therefore under the impression Mr Sanders was still receiving treatment.
Glenn Sanders died of injuries received at 1.40am on April 14, 2014, when an explosive vest he was wearing exploded. He was killed instantly.
Two Victoria Police special operations group officers were also injured, one suffering life-threatening injuries.
Coroner John Ollie found it was not reasonable for the doctor and police not to be notified that mental health services had closed Mr Sanders’ file especially in light of his severe mental health condition, lack of engagement with clinicians, concerns of police, his drug abuse and his medium risk assessment of causing harm to others.
He said Southwest Healthcare publicly acknowledged severe shortfalls in Mr Sanders’ management while he was a client of CMHS.
“Comprehensive systemic improvements instigated since Glenn’s death graphically illustrate the determination of SWHC to review and continually improve service delivery,” he said.
Mr Ollie said Victoria Police arson and explosive squad received information from three sources that Mr Sanders was wearing an improvised explosive device, a bra filled with explosives set with triggers, on March 31, 2014, but a lack of priority was given to the information and police only acted when further information was supplied on April 11.
He said the initial information should have attracted an immediate response although he conceded it could not be said the outcome would have changed.
“I do not consider the delay a cause of the tragic outcome,” he said.
Mr Ollie said the SOG officers faced a challenging task and he made made no adverse findings in relation to their attempted arrest.
He said it was likely that Mr Sanders set a timing device when police arrived at his property at 6.50pm on April 11 which led to the explosions about seven hours later.
A massive explosion occurred behind Mr Sanders and within seconds his IED detonated, killing him instantly.
“The first explosion raised Glenn’s house. In addition three other large structures on the farm were also subsequently leveled and Glenn’s mother’s house was severely damaged,” Mr Ollie found.
“It’s likely that Glenn previously rigged his house and three other structures on the farm with explosives, which he had connected with a timing device.”
Mr Ollie said that in addition to the house and IED explosions there were six separate blasts sites around the farm.
What was known about Mr Sanders before the explosions
Mr Sanders was a highly intelligent man who could “make fire out of a bucket of water”, according to his friend Kevin Simpson.
He worked as a mechanic in his teen years and later for himself doing mechanical and explosive work.
Mr Sanders was married to Susanne Sanders from 1998 to 2008 and was using marijuana and speed by 2007.
At this time he became paranoid and was ‘on edge’, his former wife told Mr Ollie.
His paranoia became worse and he began to develop conspiracy theories, according to Mr Simpson.
“The paranoia kicked in to the point where he believed that everything around him was for a reason,” he said.
“The conspiracy theories were crazy, he had a conspiracy theory for everything. Common theme was that he believed he was being watched. He said the ‘bundies’ was watching him. I have no idea who (he) is talking about.”
Residents who encountered Mr Sanders became concerned about his mental health.
Gary Poole told Mr Ollie that Mr Sanders would talk about people tracking him through his computer and mobile phone.
He set up CCTV cameras on his property to monitor people coming and going.
In September 2013, Worksafe inspectors attended Mr Sanders’ property.
He was advised his explosives licence was suspended and he was required to surrender all explosives.
Mr Sanders showed inspectors where he stored the explosives - a shipping container.
Inspectors also checked other structures but after the explosion on April 14, 2014, police found an underground bunker and a buried shipping container which were not found on that day.
An inspector admitted the dog squad would have been of assistance during the search of the property.
The coroner heard that in the 12 months prior to Mr Sanders’ death, numerous residents saw him wearing a improvised explosive device under his clothes.
“Around Christmas time 2013, Glenn informed a local businessman the farm was booby trapped,” the coroner was told.
“Further, that the entire farm would blow up and he would take as many people as he could.”
Police were informed in May 2013 by an anonymous male that Mr Sanders had strapped explosives to himself and was going to blow himself up.
A personal warning flag on Mr Sanders’ police record urged members to approach with caution and back up if visiting his property.
On October 28, 2013 two police officers visited Mr Sanders’ farm.
When asked about the rumours, Mr Sanders told police the town had nothing to fear – he just wanted to be left alone.
On April 4, 2014 the arson and explosives squad sought permission for a search warrant of the farm.
On April 9, police were contacted by Mr Poole, who told them Mr Sanders had trapped him inside his garage.
Mr Poole managed to escape the pit.
On April 11, police began to observe Mr Sanders, who drove to Ballarat to visit his mother in hospital.
Police were informed by Andrew Sanders that his brother Glenn was wearing and IED on his body.
Mr Sanders returned to his farm at 6pm and police decided to put up a safe perimeter around the farm.
Negotations commenced about 6.50pm with Mr Sanders until shortly after 10pm.
During this time Mr Sanders was co-operative and told police he didn’t want to hurt them.
Mr Sanders refused to remove his vest when asked by police
Police repeatedly asked Mr Sanders to remove the vest containing the explosive device during the negotations.
“Sorry Grant, I’m not going to do it, the only way the vest is coming off is when it blows up,” he told police.
However, he apologised profusely.
“I don’t want to hurt police, police are just doing your job … I don’t want any police to be hurt when the vest goes off.”
The coroner’s findings
- Members of the public who did not alert police about the IED did so because they were concerned for their safety, police safety and Glenn’s safety.
- Police were unable to substantiate reports Mr Sanders was wearing and IED.
- There is no evidence Mr Sanders was hiding explosives in the underground spaces on the day his property was searched.
- Mr Sanders was suffering from either Delusional Disorder of Schizophrenia marked with persistent paranoia and persecutory themes and was unwilling at later stages to seek mental help.
- GP Dr Fitzpatrick and police were not notified when Mr Sanders’ case was closed. This was deemed a serious oversight.
- The outcome may not have been different if the arson and explosives squad had acted on the information it received in early April.
Comments from the coroner
“Glenn wore an IED and any endeavour to arrest him would have been frought,” Mr Ollie said.
“Further, in respect to the arrest plan, I do not consider anything further could have been undertaken to avoid the tragic outcome.”
“Despite the tragedy of Glenn’s death, together with serious injuries to SOG officers, Victoria Police strove to safely arrest Glenn and avoid potential civilian casualties. They faced a challenging task. I make no adverse findings in respect to the attempted arrest.”