Coroner reports on Bunnings-related death

The video footage, available through news.com.au, is highly confronting. Two men crouch on either side of another man held prone on the ground.

Footage shows Anthony Georgiou pinned down, struggling to breathe, hours before death

Both the prone man's arms are held behind his back, one by each of the other men, as he screams, "I can't breathe! Help! I can't breathe!"

That took place around 11:00am on a Monday morning, 12 September 2016. (We note that this was three and a half years before the murder of George Floyd by police in the US, which renewed the efforts of the Black Lives Matter movement.) The location of the event was the Bunnings Warehouse store in Frankston, Victoria.

The man being restrained was Anthony James Georgiou (friends called him "AJ"), a 31-year-old former bricklayer. The two men who restrained him were Abdul Brenzai and George Oyee. They were employed through an outside contractor as "covert operatives" to prevent loss through store theft in that Bunnings store.

Police arrived at 11:12am. Mr Georgiou reported being "sore all over" his body, and the police called for an ambulance. Some 33 minutes later, at 11:45, Mr Georgiou was being triaged at Frankston hospital. The police spoke to him at 3:30pm that day. He died later in the day, though the exact time of death is not recorded in the coroner's report.

The causative event behind Mr Georgiou's detention right before his death? Mr Brenzai and Mr Oyee believed Mr Georgiou had attempted to steal a saw blade.

Obviously, that's not an outcome anyone wanted, including Mr Brenzai and Mr Oyee - as well as Bunnings itself. The medical forensics indicated what a specialist forensic pathologist called a "perfect storm" of medical conditions contributing to the death of Mr Georgiou. However this was paralleled - according to the coroner's report - by a process that seems to have nearly negated the series of safeguards Bunnings had attempted to put in place on the behaviour of its "covert operatives".

For those of us who spent some time during Melbourne's initial long COVID-19 lockdowns watching the public state inquiry into the failures of the quarantine system, all this has a familiar echo. The Victorian Department of Health employed security guards to manage quarantine, as Victoria police refused participation. The result was undisciplined chaos. Who can forget, for example, the security guard who was placed in quarantine after exposure, got bored, and took up a job delivering takeaway food to households during his isolation period? As a workforce, they were utterly unsuited to their task.

In a somewhat similar outcome, the coroner did not see any of the matters discussed below as being directly contributive to the highly unfortunate and very sad death of Mr Georgiou. Perhaps the most essential of his statements is this:

Mr Brenzai and Mr Oyee gave evidence that they acted in self-defence. On the basis of the material before me I am unable to gainsay these assertions.

That said, HNN still thinks it is worth pursuing this matter at some length. The reason for this is that there is an ongoing dispute, argument and, hopefully, discussion about hardware retail and the form it should take.

Independent hardware retailers believe that to operate this form of retail successfully requires a depth of knowledge that exceeds that of other forms of retail. There is just too much at stake to do otherwise.

Bunnings and other corporates tend to disagree. They believe that codes of practice, training, safe systems and good management can work just as well.

There is much to be said on both sides, but HNN would suggest that the set of events surrounding the death of Mr Georgiou really does illustrate the limits to the Bunnings-style model. That's not because Bunnings was careless, or ill-prepared for what happened. On the contrary, the big-box retailer had Codes of Conduct and a training day for the employees engaged in "covert operations" around loss control.

The most important thing the coroner has to say is that he is not convinced that even if Mr Brenzai and Mr Oyee had signed the Code of Conduct, attended the training day, and understood what was required in terms of avoiding physical engagement, that this would have made much difference.

The reality is that probably Mr Brenzai and Mr Oyee should never have been put in the position they were in, not just as loss prevention staff, but also operating covertly. What was needed wasn't a set of guidelines, it was experience, and a real "feel" for the retail environment.

Basically, if you actually have to tell a staff member "don't get into a brawl with a customer under any circumstances", then you've already made a mistake. Nobody in independent retail has a rule book that begins with Rule No. 1 "Don't punch the customers."

The simple truth is that not everyone is cut out to work in retail, and that applies double to home improvement retail.

The coroner's report

Nearly six years after the event, the Victorian Coroners Court has released its findings. (That's not an uncommon delay for the Court, which has suffered a severe backlog for some time.)

Coroner's Court findings (pdf)

The end finding of that report is as follows:

However, the coroner also acknowledges that there may be more to this death than a medical condition:

66. Dr Brouwer's report sets out that medical cause of death and further explains the role of the struggle between Mr Georgiou and Messrs Brenzai and Oyee being at least a cause of the manifestation of the conditions which led to Mr Georgiou's death. That is, there seems little doubt that had Mr Georgiou not been involved in the struggle with Messrs Brenzai and Oyee he would have walked away from Bunnings that day.

67. Submissions made on behalf of Bunnings support this conclusion.

68. Such a conclusion is not a statement that anyone is, or may be guilty of a criminal offence, nor is it a determination of civil liability but it 'points up' the most significant issue in the Inquest - how the struggle involving Messrs Brenzai, Oyee and Mr Georgiou could have been avoided.

That finding largely repeats the statement made by Dr H. Bouwer, a specialist forensic pathologist practising at the Victorian Institute of Forensic Medicine. In more detail, Dr Bouwer's report stated that the Mr Georgiou's death was triggered by electrolyte imbalance leading to rhabdomyolysis, which, as explained by Dr Bouwer, is:

...the break-down of cells which can occur after a violent, physical, activity or a struggle the effects of which can be complicated by methylamphetamines.

Dr Bouwer explained that in the setting of physical exercise or strenuous activity the heart rate and blood pressure go up, adrenaline and noradrenaline are released causing stress on the heart. Methamphetamine increases the release of adrenaline and noradrenaline creating more stress and has a direct effect on the heart muscle.

However, Dr Bouwer also left open the possibility that other injuries may have contributed to Mr Georgiou's death. In particular, he noted an unusual pattern of fractures in Mr Georgiou's thyroid area.

Dr Bouwer described his examination of Mr Georgiou's body revealed bilateral superior thyroid horn fractures associated with haemorrhage, facial suffusion, bilateral conjunctival petechiae which he said is usually caused by pressure applied to the 'Adams Apple' area of the throat. Whilst Dr Brouwer was unable to describe how much pressure would have been necessary to cause the fractures to which he referred, he explained that in younger people, such as Mr Georgiou, the structures are more cartilaginous than in older people where they are more ossified and in younger people more pressure would be required to cause such fractures.

Dr Bouwer commented that these injuries did not appear to be immediately fatal because the deceased spoke to police after Dr Bouwer thought that they occurred. Dr Bouwer gave evidence that if these injuries inhibited breathing, then they may have contributed to the cascade of events which resulted in Mr Georgiou's death. That is, a headlock, depending on how it was applied, may have caused the injuries, and if a headlock did cause the injuries and restricted Mr Georgiou's ability to breath, that this too may have contributed to the cascade that caused his death.

This takes us to the description of the actual encounter between the "covert operatives" and Mr Georgiou. With the benefit of some CCTV footage (though the area where the scuffle occurred had only indirect coverage) the coroner was able to construct a step-by-step scenario. It goes like this:

The "covert operatives" say they observed Mr Georgiou remove the tag from a saw blade and place this in a pocket. He went to the register and paid for a number of other items, but was not seen to pay for the blade.

Mr Georgiou leaves the main store and enters the enclosed space outside the doors, where he stops for a drink of water.

The "covert operatives" approach him. They request that he return unpaid items and accompany them back into the store.

According to testimony by Mr Oyee, Mr Georgiou told them he didn't want to go back into the store, but agreed to give them the items he had in his pocket.

When the "covert operatives" insisted he return to the store, he told them to "F*** off", and started to force his way past them.

As Mr Georgiou pushed past them, Mr Oyee took a 25cm long gas cylinder from him. Meanwhile, Mr Brenzai ends up with his left arm wrapped around Mr Georgiou's neck, in what the coroner describes as a "head lock".

According to the coroner's interpretation of the CCTV: "A vigorous struggle ensues, and Mr Brenzai can be seen to punch and knee Mr Georgiou."

The struggle goes on from around 11:00am to 11:06am. The police arrive about 11:12am.

Testimony of the covert operatives

Mr Brenzai and Mr Oyee were employed by security firm New Security Solutions (NSS), originally through a subcontracting arrangement with a man named Ali Haidar. In June 2016, the two men began working for NSS directly, an arrangement which was "formalised" in September 2016, but it's left less than clear exactly when that happened. Interestingly, when asked about his employment with Mr Haider by the coroner:

Mr Brenzai said that he couldn't remember when he started work with or for Mr Haider or how Mr Haider paid him.

It's perhaps helpful to add this rather short but pithy remark made by the coroner in the summation paragraphs of his report.

Despite their best-efforts police have not been able to locate Mr Haidar.

The three key points that were brought up by the coroner were: could Mr Oyee and Mr Brenzai have de-escalated the conflict; if they signed a copy of the Bunnings Covert Operative Instructions Code of Conduct and were therefore responsible for its content; and if they attended a training course held by Bunnings at its Melbourne head office for covert operatives on 19 August 2015.

De-escalation

When the coroner asked Mr Oyee why the two men didn't just step away from Mr Georgiou, Mr Oyee replied he didn't want to turn his back on the former brickie. The coroner pointed out that he could have stepped back without turning his back.

Coroner: So, you could've stepped away from him while you were looking at him. Is that right?

Mr Oyee: That's right. But the whole issue, your Honour, I wanted to prevent the product off him. I wanted to get the stuff off him.

Coroner: Get the stuff off him?

Mr Oyee: And wanted to take him up to upstairs to get the paperwork.

Coroner: To get the paperwork?

Mr Oyee: At the end of the week, you have to do the report to, ah, to NSS.

In a slightly inchoate statement, Mr Brenzai declared that he did not simply let Mr Georgiou go because:

We feared for our own safety with this gas bottle.

This was despite Mr Oyee removing the gas bottle during the first minute of the attempted "arrest".

Code of Conduct

According to the coroner's report:

Mr Oyee was shown the Bunnings Covert Operative Instructions Code of Conduct. Mr Oyee gave evidence that his signature was on the copy of this document at p.168 of the Inquest Brief but that he didn't remember signing any such document and that the document didn't look familiar to him.

When shown a copy of the document, the testimony went like this:

Coroner: And that's a document you signed? Is that right?

Mr Oyee: Yes, Your Honour. I haven't directly signed.

Coroner: I beg your pardon?

Mr Oyee: I haven't directly signed.

Coroner: Is that your signature?

Mr Oyee: It looks like my signature, but I have a doubt.

Coroner: I'm sorry, I don't understand?

Mr Oyee: It doesn't look like my signature.

It goes on like that.

As the coroner sums up the exchange:

Mr Oyee gave evidence that he had never seen the document at page 306 before and that it wasn't his signature at the bottom and that nobody from Bunnings had told him not to engage in arguments with a customer or physically restrain an offender except in self-defence.

Mr Brenzai related a similar account, according to the coroner.

46. Mr Brenzai was shown a document "Code of Conduct", attached to AM7, the same type of document that Mr Oyee was shown, this version of it ostensibly contained his, Mr Brenzai's signature. The Code of Conduct sets out Bunnings' expectations and instructions to 'convert operatives', that is 'plain clothes' security guards working at the stores looking for 'shoplifters' as Messrs Brenzai and Oyee were on 12 September 2016.

47. Mr Brenzai gave evidence that the writing on the document was not his handwriting and that the signature was not his. He explained that points 1 - 4 of the document had been explained to him verbally by Mr Naffah, a then employee of New Security Solutions, his then employer although he could not remember when. Mr Brenzai gave evidence that he had never seen the "Code of Conduct" document at page 165 of the Inquest Brief, allegedly bearing his signature. Mr Brenzai gave evidence that nobody had given him any documents or instructions about how he was to perform his role other Mr Naffah explaining to him points 1 - 4.

The importance of these signatures is laid out by the coroner, as he quotes these two key instructions from the document:

7. Never attempt an apprehension unless I am 100% certain that the offender has stolen.

8. Never engage in an argument of any kind with a customer or physically restrain an offender except in self-defence.

The signatures were, of course, witnessed - but by Mr Haidar, who, as mentioned above, seems to have become somewhat unavailable. This meant the coroner could not make a final determination on these matters. As he reported:

It is regrettable that Mr Haider could not be located - I can take this matter no further absent further evidence.

However, in summing up his findings about this area, the coroner states:

Even if the document had been signed by Messrs Brenzai and Oyee, and they had read Bunnings Covert Instructions I could not say with any degree of surety that what occurred, would not have. It is of course possible that having read those documents Messrs Brenzai and Oyee would have acted differently but on the basis of the evidence I cannot say with any confidence that this would certainly have been so.

He goes on to comment:

I am unable to be critical of Mr Brenzai or Mr Oyee for breaching the Bunnings Code of Conduct - and I am not. Their evidence is that they were simply not aware of it. As I have referred to above, even had they been, as the evidence currently stands, I am not clear that such knowledge would have made any difference to what happened.

August training course

While Bunnings might have held a training course for its "covert operatives" in August 2015, it seems this was not that memorable an event. Mr Brenzai has some recollection of attending something at Bunnings somewhere around that time, but he could not recall any of the content.

When asked about whether he recalled attending any covert operative training conducted by Bunnings, Mr Brenzai said that he had attend a meeting in the Bunnings Head Office for which was late. He initially thought that he had attended after lunch although he could not precisely remember. He said that he thought that he attended this meeting while he was working for Mr Haidar and that he, Mr Brenzai was late - he didn't remember if he went back after lunch. He conceded that it may have been August 2015. Mr Brenzai was taken to the PowerPoint slides at pages 281-304 of the Inquest Brief and told that these were presented to students at the covert operative training in August 2015 and asked if the slides or their content were familiar to him. He responded that he didn't remember.

Mr Oyee seems to have drawn a similar kind of blank regarding the Bunnings training, according to the coroner:

Mr Oyee was also shown PowerPoint presentation slides said to have been used at a Bunnings training course conducted on 19 August 2015 for covert operatives in Bunnings Stores.

Mr Oyee gave evidence that he could not remember if he had attended that training session and that the slides didn't look familiar to him. Mr Oyee gave evidence that he didn't recall going to any meetings of security staff or being provided any training at all by Bunnings.

In the summation paragraphs, the coroner states:

Mr MacDonald, the then National Investigations Security Manager for Bunnings gave evidence that Bunnings had no evidence that Mr Brenzai or Mr Oyee attended the training session on 19 August 2015.

It's unclear whether attendance was taken, but the two "covert operatives" did not sign in, or if no efforts to record attendance were made.

However, again, the coroner does not believe that attendance or non-attendance were determinative:

There seems to be no controversy that Messrs Brenzai and Oyee didn't complete a full day's training on 19 August 2015. There is however insufficient evidence for me to conclude that if such training had occurred that Mr Georgiou would not have died as he did.

Analysis

Just about everyone in hardware retail - including suppliers - who reads this story is probably as much puzzled as horrified by these events. That is just not how you do loss prevention. Really.

Why didn't the "covert operatives" simply calmly confront Mr Georgiou immediately after he made his other purchases, and say something like - pleasantly but firmly - "Mate, I reckon you might have forgotten to pay for the saw blade in your pocket, right?" That would have made the point, retrieved the allegedly stolen property, and burned up as few resources as possible.

Or, later, after Mr Georgiou was confronted and offered to give the saw blade back, but refused to return to the store, why didn't Mr Brenzai and Mr Oyee simply accept that offer, and cut their losses? By all accounts, whatever his concealed ailments, he was, well, built like a brickie - a really big, solid guy. Plus, of course, he was under the influence of methylamphetamines. Most retailers know when they are dealing with a drug-addled customer.

Every single independent retailer knows how to de-escalate and deal with that situation. You don't need to hurt anyone physically, when you can publicly shame or poke fun at the perpetrator. Often you just wait until the next time they visit the store - or try to.

The odd thing is that HNN has been witness to just exactly this type of good judgement by Bunnings staff in the past. We've seen some young kid (probably a poor apprentice) get stopped on the way out of the Hawthorn Bunnings, and take to his heels, closely chased by a staff member - who was called back immediately by a manager.

Afterwards, the manager and the staff member had a very quiet chat. The manager pointed out, very seriously, that the staff were under no circumstances to place themselves in that kind of danger, adding that they were also endangering the customer. As the manager said, very clearly, "It's never worth it".

This also brings to mind, of course, the recent controversy about Bunnings using facial recognition over its CCTV systems to track loss prevention. As HNN wrote at the time, looking at the protections Bunnings has in place, these all seemed very reasonable, and almost a draft for future regulations. But are the assurances the company gives us about how it handles privacy going to result in better outcomes? Are they realised in place, or are they regulations that are seldom followed in a practical sense? The death of Mr Georgiou goes to how much confidence the public can place is guarantees issued by Bunnings.

But beyond these abstractions, there is a single truth here. There is now an eight year-old Melbourne girl who has to grow up without AJ, her Dad. There's no way to ever make that really right.

It would be good if everyone in our industry can just try to make sure this doesn't happen again. We can start by respecting expertise, training and experience, rather than just taking the cheap option.