An inquest will not be held into the murders of two women at the Ashburton WINZ office in 2014 as the Coroner is satisfied enough changes and improvements have been made by the Ministry of Social Development to prevent similar tragedies in future.

And an apology has been made to the families of the victims and the survivors for the length of time it took to wrap up the coronial process - almost nine years after the mass shooting.

Receptionist Peggy Noble, 67, and case manager Susan Leigh Cleveland, 55, were shot dead by Russell John Tully after he stormed the WINZ office where they worked on September 1, 2014.

Tully was jailed for life with a minimum non-parole period of 27 years for murdering the women; and the attempted murder of case manager Lindy Curtis.

The victims, from left: Peggy Noble, Lindy Curtis and Leigh Cleveland. Photo / APN, supplied

In 2016 the Ministry of Social Development - the government agency that oversees WINZ - was prosecuted by WorkSafe for breaching the Health and Safety Act by failing to take all practicable steps to protect its staff.

The ministry accepted five of the six practicable steps which WorkSafe alleged it failed to take, but did not accept the first step, which was ensuring there was no physically unrestricted access by clients to the staff working area.

Judge Jan-Marie Doogue later ruled that MSD should have taken such a step.

Following the Tully and MSD convictions Coroner Ian Telford considered whether an inquest should be held.

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In February he ruled that an inquest was not necessary and in his decision released to the Herald today, he explained why.

He said MSD had accepted it failed to:

• Ensure that employees and contractors were adequately trained to respond to an emergency response incident;
• Adopt and effectively embed a “zero tolerance policy” prior to the incident including “strategising to create a positive security culture” and implementing such strategies;
• Implement a client risk profiling process:
• Implement a client management plan tailored to the risk of assessment of that client;
• Implement effective incident investigation and incident data analysis, including by not engaging “periodically with selected frontline staff from selected locations to evaluate the effectiveness of security-related systems”.

Coroner Telford said as part of his investigation MSD had provided “detailed information” relating to the steps it had taken following this incident - and the legal proceedings.

CCTV image of Russell John Tully during his armed attack on a WINZ office in Ashburton, in September 2014.

In July 2021 it provided a “comprehensive report” which set out “an extensive range of protective steps” it had taken – both in the immediate term following the tragedy and through an “ongoing programme of work”.

“This programme is detailed and has been heavily resourced,” the Coroner said.

“Given the passage of time, I invited MSD to provide an update on the situation… On 21 February 2023, I received a further report which assures me that the work programme is continuing to be implemented and further developed.”

Coroner Telford apologised to the families of Noble and Cleveland and others affected by the shooting for the time it took for him to release his decision.

“This is the most awful tragedy… I apologise that the coronial process has taken so long to conclude.

“However, my investigation following the conclusion of the criminal proceedings was necessary – particularly to ensure that all possible processes were in place to prevent deaths occurring in similar circumstances.”

Tully in court. Photo / Pool

The Coroner said he had chosen not to publish the specifics of the MSD work programme to “protect the integrity of security plans and processes within the organisation”.

“However, I am satisfied that these processes are appropriate and that best endeavours are being employed to prevent this kind of situation happening again,” he said.

“I have therefore decided that further investigation of this matter and the opening of an inquiry is not required, as the primary focus of such an inquiry would be to establish whether recommendations and or comments are needed to reduce the chances of further deaths occurring in similar circumstances.

“I am satisfied that the processes instigated by MSD require no such comment or recommendation from this Court.”

Evidence at the High Court trial in Christchurch for Russell John Tully. Photo / POOL

Coroner Telford offered his “most sincere condolences to all that have been affected by this tragedy”.

“This was an inexplicable act of violence that shocked and deeply disturbed New Zealanders - particularly the people of Ashburton and wider Canterbury community,” he said.

“It is an act that has undoubtedly led to incalculable pain and suffering for the family, friends and colleagues of Ms Noble and Ms Cleveland.”

SEPTEMBER 1, 2014 - WHAT TULLY DID

On the morning of September 1, 2014, Russell John Tully entered the WINZ office in Ashburton.

He was well known to staff at the office as a problematic client and had been trespassed a month earlier for being increasingly “demanding”, “manipulative” and “quietly intimidating”.

By the day of the shooting he was angry and annoyed - he felt aggrieved over what he perceived as being “unfairly treated”.

At 9.51am he walked into WINZ wearing a balaclava and armed with a pump action shotgun.

He entered the public reception area and moved towards the reception counter where Peggy Noble was working.

The police cordon at the Ashburton WINZ office where Russell John Tully went on his shooting spree. Photo / Mark Mitchell

He discharged his shotgun at point-blank range at the woman, killing her instantly.

He then moved past the reception area into the body of the open-plan office.

He discharged his shotgun at another employee but missed. She escaped from a nearby door.

Tully then located Lindy Curtis hiding underneath her desk with a client. He shot her but not the client.

Curtis was injured but survived.

Tully then proceeded to the rear area of the office space towards Susan Leigh Cleveland.

She was behind her desk which was in the corner of the office space, and unable to escape.

Tully shot Cleveland and started to walk away - before returning back to where she was lying to shoot her a second and third time. She died at the scene.

Tully then left the WINZ offices and escaped using a bike along the Ashburton Riverbank.

He was subsequently located and arrested by police.