Inquest into the Death of Joyce Gladis CLARKE
Inquest into the Death of Joyce Gladis Clarke
Delivered on : 9 June 2025
Delivered at : Perth
Finding of : State Coroner Fogliani
Recommendations :
Recommendation 1
I recommend that consideration be given to establishing a section or branch of the WA Police dedicated to improving the relationship between WA Police and Aboriginal persons, and that there be consultation with Aboriginal persons in connection with the role of this section or branch.
Recommendation 2
I recommend that WA Police oversee Aboriginal Cultural Awareness training, to be co-designed with, and delivered by, Aboriginal persons, including face to face training on a regular basis, that consideration be given to tailoring it to the region in which the police officers are serving, and that consideration be given to emphasising the importance of the effect of intergenerational trauma, and foetal alcohol spectrum disorder, and the importance of cultural wellbeing.
Recommendation 3
I recommend that First Class Constable Cleghorn, Senior Constable Walker, First Class Constable Caracatsanis, Senior Constable Cooney, Senior Constable Bird and Constable McLean be de-briefed by Mr Markham or similar trainer as to the events of 17 September 2019 (including as to de-briefing on the cordon and containment).
Further, that Mr Markham or similar trainer incorporates within the ongoing WA Police training, scenario based training drawn from the learnings from this incident.
Recommendation 4
I recommend that WA Police continue trialling and considering the future use of new conducted energy weapon platforms (such as tasers).
Recommendation 5
Noting the existing statutory framework concerning the treatment and care for Aboriginal and Torres Strait Islander people provided for under the Mental Health Act 2014 (WA), to further support culturally safe and responsive health care, I recommend that health service providers prioritise their engagement in the nationally agreed development of the Implementation Plan for the Gayaa Dhuwi (Proud Spirit) Declaration.
Recommendation 6
I recommend that, with the consent of the patient, a discharging health service provider consider notifying a local health service to advise that service that the patient is returning to Country, or to an area where they habitually reside, even if at that time, there is no need for an active referral to that local health service.
Recommendation 7
I recommend that the Director General of the Department of Health consults with the WA Police to continue to work on how relevant information, pertaining to a person’s mental health, can be shared between the agencies in such a way that balances privacy with imminent safety risks.
Recommendation 8
I recommend that the Mental Health Co-Response continues to be funded and that WA Police consult with stakeholders including the Department of Health, WA Country Health Service and/or the Mental Health Commission, to continue to revisit the model for the Mental Health Co-Response, in particular to explore ways in which an authorised mental health practitioner may give support and advice to police attending an incident involving a person experiencing a mental health crisis.
Recommendation 9
I recommend that WA Police consider a review of the training of police officers, in particular the In-Service Critical Skills training 1, 2, 3 and 5 (or equivalents) to assess whether aspects of the Use of Force training could be usefully integrated with the effective communication training, and to consider the effectiveness of audit processes in respect of the training.
Orders/Rules : N/A
Suppression Order :
That there be no reporting or publication of any details of any information in any document or evidence given that would reveal:
- The technical aspects of a taser or a firearm, being their effective distance and effective positioning, limitations on their effective capabilities, and the effective method of deploying (including drawing and covering) a taser or a firearm; or
- The fact of any taser conducted energy weapon currently being considered for use in Western Australia and any pilot program or roll out plans in relation to that weapon, and in any other jurisdiction.
For the avoidance of doubt, the suppression order does not, and cannot, extend to the suppression of information already in the public domain; and does not prohibit the reporting or publication of the events or the decision making processes of the individual officers on 17 September 2019.
Summary :
Joyce Gladis Clarke (JC) was 29 years old at the time of her death, which occurred on the evening of 17 September 2019 in Geraldton. JC died as the result of a gunshot injury after she was shot by an on-duty member of the WA Police Force. That officer, Mr Wyndham, was later arrested and charged in relation to her death.
On 22 October 2021, following a trial before the Supreme Court of Western Australia, a jury found Mr Wyndham not guilty of the charge of murder, and not guilty of the alternative charge of manslaughter.
Following the conclusion of the Supreme Court proceedings, the State Coroner held an Inquest into JC’s death. The Inquest heard that following her release from prison, JC struggled with the transition, and had unfortunately relapsed into drug use. As a result, and also due to her uncertainty about her housing situation, JC experience a turbulent period in her mental health, and she was admitted to Geraldton Regional Hospital. Due to management issues that JC presented on the ward, the decision was made to transfer her to Sir Charles Gairdner Hospital for further management. JC was held as an involuntary patient under the Mental Health Act for this transfer to occur.
The Inquest heard that during her admission to Sir Charles Gairdner Hospital, JC was given the working diagnosis of drug induced psychosis and suicidal ideation, and it was noted her lack of stable accommodation was causing her some distress.
The inquest heard that on 13 September 2019, JC was discharged from Sir Charles Gairdner Hospital, following which she returned to Geraldton. The State Coroner was satisfied that the discharge was reasonable, given her drug-induced psychosis had resolved, although it was noted there was room for improvement in regard to her referrals and notifications to services back in Geraldton.
During the course of the Inquest, the State Coroner heard evidence regarding JC’s movements and her interactions with members of the Geraldton community and her loved ones in the lead up to her death. It is apparent that JC was under the influence of drugs during this time, and her behaviour was at times volatile, which was increasingly concerning to her family.
The Inquest heard that on the day of her death, a call was placed by a member of JC’s family, stating that she had left the residence armed with a knife and they were concerned for her. A subsequent call was placed to police when a member of the public observed a person walking armed with a knife in the area. This call did not identify the person as JC.
The Inquest heard detailed accounts of the resulting actions taken by police, including the tasking of police resources for those two calls, and their communications over the radio and in person in the minutes prior to the shooting. The tasking for both the calls placed to police ultimately resulted in a number of police vehicles being present and converging on the scene prior of JC’s shooting. The Inquest heard detail on the timing of actions that led to Mr Wyndham discharging his police firearm, which occurred within 17 seconds of him exiting his police vehicle.
The Inquest examined a number of issues surrounding the death, including the actions of police on the day, and the question of whether the shooting could have been avoided. The State Coroner heard extensive evidence from police officers present at the time of the shooting, with regard to their decision-making processes, their use of force options and their actions and communications.
The State Coroner found that Mr Wyndham, the police officer who shot JC ran towards the threat and put himself in a position where he perceived the need to fire his gun. Mr Wyndham did not consider communicating with the other police officer who was out of his car to reduce the threat. It was not possible to tease out the extent to which Mr Wyndham was affected by body alarm reaction. The State Coroner was satisfied that JC neither lunged nor stepped towards Mr Wyndham, though it is likely there were some movements made by JC in her upper body that he interpreted as a forward momentum.
The State Coroner found that there were a number of missed opportunities on the day that could have de-escalated the situation. Her Honour was satisfied that JC’s death was a preventable death. Consistent with the Supreme Court ruling, her Honour found that the death occurred by way of lawful homicide.
The State Coroner commented on the importance of acknowledging the overwhelming harmful social factors that characterised JC's life and that predisposed her to the social determinants of ill health, that in her case could be seen in episodic deteriorations in her mental health. The State Coroner could not exclude her having a psychotic episode at the time she was shots.
The State Coroner made a number of recommendations aimed at preventing circumstances similar to those surrounding the death of JC from occurring again. Those recommendations were aimed at addressing not only training and use of force options available to officers on the day, but larger cultural and institutional changes within the WA Police Force and Department of Health agencies.
Catch Words : Mandatory Inquest : WA Police Force : Gunshot Injury : Mental Health Services : Mental Health Co-Response : Mental Health Commission
Last updated: 2 July 2025