Indigenous Deaths in Custody: Part E Profiles: Indigenous Deaths in Custody 1989 - 1996

Part E Profiles: Indigenous Deaths in Custody 1989 - 1996

New South Wales
Victoria
Queensland
Western Australia
South Australia
Tasmania
Northern Territory
Other Deaths in Custody
Glossary


Victoria

8VIC 2/11/89 25

M

Police Gippsland Hospital, Sale Natural
31VIC 29/8/91 39

M

Police Bendigo Police Sation Self-inflicted
36VIC 10/2/92 28

F

Police Police Van, Prahran Self-inflicted
47VIC 24/2/93 24

M

Prison Pentridge Prison, Coburg Self-inflicted
48VIC 3/8/93 33

M

Prison Metropolitan Remand Prison Natural
66VIC 23/9/94 42

F

Police Fitzroy St, St Kilda Gunshot


8VIC
Male, 25, died on 2 November 1989
Gippsland Base Hospital, Sale, Vic
Pneumonia following brain damage

Coronial Inquiry Finding handed down on 22nd March, 1992

Jonathon George Klestadt, Coroner

Finding

That the death occured as a result of cardiorespiratory failure as a result of pneumonia from the aspiration of fluids in the chest cavity following brain damage. The deceased was found to have contributed to his death by his excessive intake of alcohol and his neglect of his own nourishment. The attending doctor at the hospital and the police forensic surgeon were also found to have acted unreasonably in relation to the transfer of the deceased from the Gippsland Base Hospital to the Sale Police Station.

Summing Up

Circumstances of death

The deceased had a history of chronic alcoholism and epilepsy. He had been released from prison about two weeks prior to his death. For about four days up to Sunday 24 September he had been binge drinking at a relation's house. On Sunday he complained he felt he was going to have a fit, and was taken by ambulance to the Gippsland Base Hospital. The Coroner found he was mildly intoxicated, but not yet suffering the effects of brain injury. He was given anti-convulsant medication and driven home.

On Monday 25th at about 9am the deceased suffered a 'grand mal' seizure, and was again taken to the hospital. He arrived at the hospital quite calm, but became aggressive when the Resident Medical Officer tried to examine him. He remained disruptive for some time, and the police were called.

The police arrived as the deceased was 'lying on the floor, �behaving in an irrational manner, was incoherent, was clenching and unclenching his fists and making his arms rigid, and had a vacant staring look.' They concluded the deceased was highly intoxicated, and that the resident was inexperienced and was not coping. They refused to assist the resident to attempt examination and diagnosis due to a manpower shortage back at the police station. The deceased was handcuffed, charged with public drunkenness and taken to the police cells in Sale.

The police surgeon performed a 'fairly perfunctory check' at approximately 1pm and declared the deceased fit to be detained. At approximately 10pm the police surgeon walked into the cell and found blood and saliva to be emanating from the nostrils of the deceased. The deceased was again removed by ambulance to Gippsland Base Hospital, where he died of pneumonia associated with hypoglycaemia and brain damage after remaining in a coma for over a month.

Issues

The Coroner found on the evidence that he had consumed a relatively small amount of moselle before he had the fit on the Monday, but was not highly intoxicated as medical staff and police later reported.

The Coroner found the inexperienced resident medical officer at Gippsland Base Hospital was overwhelmed and reacted to the deceased as 'an aggressive, volatile, drunken Aboriginal.' The Coroner did not accept his statement that he considered acute brain syndrome, or that he related this possibility to other doctors or police. The Coroner also stated in regard to the nurse 'I find that her dismissal out of hand of any other possible cause of the deceased's behaviour [than intoxication] was surprising.' He made the comment because the deceased had come to the hospital in an ambulance following an epileptic seizure. He found that the doctor related only the bare facts that the deceased was intoxicated and aggressive to the resident physician, who agreed on that basis that the police should be called.

The Coroner found a 'tragic lack of communication' of the reasons for hospitalisation resulted in the police charging the deceased with public intoxication and removing him to the police cells in a van at about 11am on Monday, and that this was the precipitating event in the death. The Coroner did not believe it necessary to find whether the hypoglycaemic episode began at the hospital or later at the police cells.

The police forensic surgeon was found to have failed to give a sufficient or adequate degree of attention to the whole issue of the deceased's medical condition and his fitness for transfer to the police station from the hospital.

Recommendations

That the case be referred to the Victorian Attorney-General for his attention with the recommendation that it be referred to the Law Reform Commission for consideration as a case study in what can go wrong in the existing legislative framework (public drunkenness a criminal offence).

That where any transfer such as this occurs between a medical institution and police custody that the person being transferred be accompanied by complete copies of any medical record or notes which have a bearing on his condition at the time of his transfer.

Royal Commission Recommendations Breached

R79 Abolition of offence of public drunkenness.(IR3)

R80 Adequately funded custodial care to accompany abolition of this offence.(IR4)

R81 Statutory duty to consider and use alternatives to police detention of intoxicated persons.(IR5)

R87 Police to apply arrest as a final sanction, and implement practical procedures to ensure this occurs.(IR8, IR9)

R127e Liaison between police and Aboriginal health services to ensure transfer of information.

R127f(i) Rules for care and management of Aboriginal prisoners at risk because they are intoxicated.

R252 Review of casualty procedures in hospitals regularly attended by Aboriginal people to minimise risk of incorrect diagnosis and treatment.(IR42)

Social Justice Commissioner

Comment

The Coroner stated that criticism of the senior police officer involved which could be implied from findings about the doctors involved were of a minor nature, and that his actions were mistaken but reasonable. The Coroner stated that the inquest was an investigation of the reasonableness of actions based on the available information and without the benefit of hindsight. The main focus of the coronial inquiry was individual blame. There was no preventative analysis of, or recommendations for, police behaviour towards persons suspected of being intoxicated. As the police were acting with very little information, the Coroner carefully avoided blaming them. However, to handcuff a semi-conscious man, convey him to police cells and hold him while not rouseable for more that ten hours is not appropriate.

The Coroner made no reference to interim report recommendations about the recording of, or the timing and quality of, inspections of detainees in police custody. He accepted the statements on this issue, and neglected to comment that they fell short of the Royal Commission standards - inspection every 15 minutes for the first two hours and hourly checks thereafter, with greater frequency in cases of medical risk.

The previous year six non-Aboriginal people in Victoria had died in police custody following arrest for public drunkenness, and in November 1992 a Victorian death again involved head injuries misdiagnosed by police as drunkenness.

The prisoner was reportedly checked hourly, less frequently than a detainee from a hospital should have been checked (R137). The checks were not recorded (R138).

Hospital emergency unit medical staff should be better trained in the diagnosis and care of persons suspected of being affected by drugs and alcohol. The reaction of the doctor in this case was similar to that of the nurse found liable in negligence in Quayle v NSW (1995) Aust Torts Reports 81-367.

Additional Royal Commission Recommendations Breached

R126 Careful completion of screening form and risk assessment by a trained person to precede placement in a cell.

R133 Training of police officers to recognise those in distress or a risk. (IR28)

R134 Police instructions to require humane and courteous contact with detainees.
R136 People found unconscious or not easily roused to have immediate medical care.

R137 Police training and instructions to require checks of detainees. More regular checks for detainees at risk. (IR15)

R138 Police instructions to require recording of information relevant to well-being of detainees.

R144 Aboriginal detainees not to be left alone in police cells; place with other Aboriginal person.

R163 Regular police training in restraint procedures; restraint aids to be applied as a last resort.

R247 More/improved training of non-Aboriginal health professionals in Aboriginal culture and society and life threatening conditions which are experienced by Aboriginal people.

R255 Addressing of negative stereotypes of Aboriginal people and people with drinking problems through staff selection, supervision and training and through clear instructions.

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31VIC
Male 39, died on 29 August 1991
Bendigo Police Station, Vic
Self-Inflicted Hanging

Coronial Inquiry Deputy State Coroner Wendy Wilmoth

Finding handed down 15th May 1992

Finding

The death was the result of self-inflicted hanging at the Bendigo Police Station.

Summing Up

Circumstances of death

In the months prior to his death the deceased had temporarily separated from his wife and had a relationship with another woman. She had fallen pregnant to him but had terminated the pregnancy. He reconciled his marriage, but he told friends and workmates of his distress at the termination. He had past problems with alcoholism, and still had lapses.

On the day of his death he attended a party at a hotel from 2pm. He drank quite heavily and lost $350 during the course of the evening. He became depressed while discussing the termination. He stayed after the rest of the party left, and attracted the attention of police outside the hotel at about 10pm. He apparently asked to be locked up because he did not want to go home to his wife after having lost the $350. He was arrested for public drunkenness and taken into police custody, reportedly in a good mood.

At 2am the deceased was told he would soon be released. He was found hanging by his shoelaces in a shower recess in his cell at about 2.35am. The shower recess was hidden to the surveillance camera. An ambulance arrived at 2.44am. Resuscitation was not attempted. The deceased was declared life extinct by a doctor at the cells at 3.30am.

Issues

The Coroner accepted that the deceased asked police to take him to the cells despite being advised to go home, and had earlier communicated his intention to spend the night in custody.

The deceased told police that he was Aboriginal, but they did not believe him. As a result the Community Justice Panel was not informed when the deceased was taken into custody (R145). Certain procedures adopted for Aboriginal detainees were not complied with. For example, shoes were taken from another Aboriginal prisoner as a precaution, but not from the deceased.

Police did not attempt resuscitation on discovering the deceased to be hanging in the shower recess of his cell. The Coroner found that there was a slight possibility that an attempt at rescusitation at 2.35am may have revived the deceased.

Recommendations

1. That in each police district in the state, police cells be inspected with a view to locating possible anchor points to which an item could be tied or fastened. An assessment should be made of the feasibility, in practical and economic terms, of rendering the anchor point unusable. A report on the inspection and feasibility of steps to be taken should be made to the Chief Commissioner of Police.

2. Paragraph 7 of the guidelines concerning community Justice Panels should be amended so that the words 'identifies themselves' are substituted by the words 'claims to be'. The guidelines should also designate the specific officer who shall contact the Missing Persons Bureau and the Community Justice Panel when an Aboriginal person is detained.
 
3. Consideration shall be given to the up-dating of printed material designated to accompany lectures to recruits. Consideration should be given to other ways of exposing recruits to information about Aboriginal culture and communities, within the constraints of time imposed by the pressure of a 20 week course. Other courses should be available at a later stage in a police member's career offering further education.
 
4. Consideration should be given to ways of improving lines of communication within the Police force. It is apparent that a substantial amount of information and understanding at the level of the highest ranks is not reaching recruits and sub-officers.

The Coroner also commented: 'It is apparent that there is considerable goodwill between the Police in Bendigo and the Community Justice Panel members. It seems generally acceptable that direct contact between the Police and the Panel when an Aboriginal person is detained, is desirable. However, for reasons of accountability the Missing Person Bureau must also be informed. As field officers of the Victorian Aboriginal Legal Service are no longer available to be conduits of the Community Justice Panels, the Police must fill this role, and so two telephone contacts must be made. It is important that this be made clear as soon as possible.'

Royal Commission Recommendations Breached

R90 Where not already in place, requirement for ALS notification of denied and unmet bail; access by ALS officers to persons held without bail and written notification of arrested persons of bail rights.

R133 Training of police officers to recognise those in distress or a risk, including the general health status of Aboriginal people.

R145 Introduction of Aboriginal Visitors Scheme.

R158 First priority on finding a person apparently dead to be resuscitation and medical assistance.

R165 Elimination/reduction of items with potential for self harm.

Social Justice Commissioner

Comment

The issue of public drunkenness being a criminal offence is slightly peripheral to this case. Nevertheless, a better environment at a sobering-up facility may have made a difference had that option been available.

The Coroner heard evidence that there was no resuscitation equipment at the watch-house, either at the time the deceased was discovered hanging or twelve months later when the inquest was held (transcript, p170). However, no recommendations were made about resuscitation equipment. Police were not questioned about the extent of their first aid training.

When examined at the inquest one police officer claimed that the entry in the watch-house book indicating that the deceased was Aboriginal was made after the night of his death (transcript, p117). The book is an important record, and it is unsatisfactory if it is being falsified.

Additional Royal Commission Recommendations Breached

R79 Abolition of offence of public drunkenness.

R80 Adequately funded custodial care to accompany abolition of this offence.

R81 Statutory duty to consider and use alternatives to police detention of intoxicated persons.

R159 Availability of safe, effective resuscitation equipment and trained staff in all prisons and watch houses.

R160 Basic training for all police and prison officers in revival techniques and annual refresher courses in first aid.

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36VIC

Female, 28, Died on 10 February 1992
Police Van, Prahran Police Station Carpark, Vic
Deliberate Overdose

Coronial Inquiry Deputy State Coroner Iain West
Finding handed down 18th May 1993

Finding

The deceased was found to have deliberately taken an overdose of theophylline tablets. 1 She attended hospital but discharged herself against medical advice without disclosing her overdose. She was taken into police custody and died while handcuffed in the back of a police van parked at the police station.

Summing-Up

Circumstances of Death

The Coroner found the deceased had taken an overdose of theophylline, an asthma medication, most likely while on police referral at a welfare accommodation hostel. She was to appear in court the next day for public drunkenness.

The deceased had a history of mental illness and drug abuse. She complained to the hostel reception clerk of abdominal pain at 3am, and he called a taxi to take her to the Albert Hospital.

The Coroner found that when she got to the hospital at about 4am she gave an incomplete history to attending doctors, withholding the fact of having taken the theophylline. Her symptoms included a heart rate (sinus techycardia) of 130-150, vomiting blood and low potassium reading of 2.9. The attending doctor described her as oriented but smelling strongly of intoxicating liquor. Toxicological analysis during autopsy was negative for alcohol. She was treated at the hospital, and given drug screening tests.

The deceased became aggressive. At about 8am she discharged herself against medical advice. Doctors at the Emergency Department decided there were insufficient grounds to hold her as an involuntary patient. She walked into the street where she changed into her clothes, and demanded a lift of a man driving a utility. The Coroner described an incident in which the deceased became aggressive and threw oil inside his vehicle. Police and a hospital security guard arrested her after a struggle. She was handcuffed, placed in a police van, and taken to Prahran Police Station. Because she had fought with police during the arrest and smeared excrement on herself during transit she was not removed from the van.

The police called the hospital for her details. Enquiries were set in train to obtain mental health certification through the police forensic surgeon at Russell Street, but she was found to be unconscious when checked ten minutes later. She could not be revived.

Issues

The Coroner found that it would not have been appropriate for the hospital to detain and sedate the deceased. However, the inability of the hospital to diagnose the patient as at risk of self harm is raised in the making of the recommendation below.

Recommendations

1. That public hospitals make available facilities and personnel, such that competent after hours psychiatric assessment can be obtained of suspected patients who may be at risk.

Royal Commission Recommendations Breached

R252 Review of casualty procedures in hospitals regularly attended by Aboriginal people to minimise risk of incorrect diagnosis and treatment. (IR42)

R255 Addressing of negative stereotypes of Aboriginal people and people with drinking problems through staff selection, supervision and training and through clear instructions.

Social Justice Commissioner

Comment

The use of the police van to hold the deceased on arrival at the station was justified by the Coroner because of the short time involved, the immediate intention to take the deceased to the forensic surgeon to have her certified, and because she was aggressive. In the difficult circumstances the Coroner avoided blaming the police or the hospital staff. However, in view of the serious issues raised a preventative role could have been more vigorously pursued. The decision by police to take her to the police station rather than back to the hospital raises the issue of appropriate response to health risks (R161). The police knew she had recently discharged herself from the hospital. The deceased was wearing a hospital band. The forensic surgeon was primarily sought to provide mental health certification rather than to treat the deceased.

The fact that the deceased was held unsupervised at the station in the back of the police van indicates a lack of protocols under recommendation 127 for the handling of persons who are (a) intoxicated, (b) angry, aggressive or otherwise disturbed or (c) suffering from mental illness.

The transcript at p116 also reveals that a senior constable was unable to locate a mouth piece for further cardio pulmonary resuscitation treatment either in the watch-house or in any of the vehicles at the station.

In the exceptional circumstances where police vans must be used as a holding facility, constant supervision must be maintained by police.

Additional Royal Commission Recommendations Breached

R13 Coroner to recommend ways to prevent further deaths.

R79 Abolition of offence of public drunkenness.

R80 Adequately funded custodial care to accompany abolition of this offence.

R81 Statutory duty to consider and use alternatives to police detention of intoxicated persons.

R127f(i) Protocols for the care and custody of persons who are intoxicated.

R127f(v) Protocols for the care and custody of persons who are angry, aggressive or otherwise disturbed.

R133 Training of police officers to recognise those in distress or a risk.

R137 Police training and instructions to require checks of detainees. More regular checks for detainees at risk. (IR15)

R135 People unconscious or not easily roused to be taken to a medical service, not a watch-house.

R159 Availability of safe, effective resuscitation equipment and trained staff in all prisons and watch

R161 Instructions to seek immediate medical care if doubts about prisoner's condition.

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47VIC

Aboriginal Male, 25, died on 24th February 1994
Pentridge Management Unit, Coburg, Victoria
Self Inflicted Hanging

Coronial Inquiry Deputy State Coroner Iain West
Finding Handed Down 13th May 1994

Finding

The deceased died in the Pentridge Management Unit (PMU) when he hanged himself with the intention of taking his own life.

Summing-Up

Circumstances of Death

The deceased had been on remand for a period of eleven months before his death, facing three charges of murder. He had a history of attempted suicide in Western Australia. His medical file indicated that on entering the prison he had been assessed as a suicide risk. He was initially placed in the Acute Assessment Unit, but the Coroner reported that he was transferred to several different divisions of the prison because of his aggressive, anti-social behaviour and a depressed mental state. The Coroner reported threats to stab an officer, assaults on two other prisoners, and an incident in which he had cut the neck of another prisoner in the Acute Assessment Unit.

He was transferred three weeks before his death to the PMU, a separation unit, reportedly on his own request. He was found at morning muster slumped against a cell wall with a television cable knotted around his neck, its end tied to another electrical cable attached to a shelf bracket.

Issues

The Coroner stated 'It is appropriate that classification personnel take into account a prisoner's previous history before placement within the various divisions within the prison and that this should include giving appropriate weight to a medical officer's opinion of the prisoner's medical state� The deceased's file did not follow him, as he was a remand prisoner.'

The Coroner found that an appropriate balance was struck between correctional and medical issues, and that this was a case in which correctional issues had to be paramount.

The Coroner found that insufficient grounds existed for the placement of the deceased in a Muirhead (suicide proof) cell under constant observation, as he had been seen by a doctor the day before the night of his death and assessed not to be actively suicidal.

The Coroner found that an investigation had led to the removal of hanging points as far as practicable in order to prevent re-occurrence of this type of incident, but that it would have been inhumane and unworkable to take this process too far.

Recommendations

1. It is recommended that consideration be given to implementing procedures that would ensure communication of relevant information from medical staff to custodial staff, so that all prisoners can be classified, not only according to corrections needs, but also their mental and physical needs.

Royal Commission Recommendations Breached

R152f Guidelines for exchange of information between medical and prison services.

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48VIC

Aboriginal Male, 33, died on 3rd August 1993
Metropolitan Remand Prison, Coburg
Epilepsy

Coronial Inquiry Deputy State Coroner Iain West

Finding handed down on 4 August 1994

Finding

The death occurred on the 3rd August 1993 at the Metropolitan Remand Prison, Coburg from epilepsy.

Summing Up

Circumstances of Death

The deceased had a history of epilepsy. He had been in prison for a portion of each year since 1983, when he received a serious frontal lobe injury as a result of an assault. He had a record of alcoholism, and had received psychiatric attention in the week of his death. He had entered the prison on remand on 19 May 1993. His daily dose of dilantin anti-convulsant medication had been reduced from 400mg to 200mg, and then increased to 300mg approximately one month before his death.

Blood tests had revealed that the 400mg dose gave a reading well above the therapeutic range, but 200mg gave a reading below the therapeutic range. The deceased had not seen a doctor since the last dosage adjustment (he had seen a psychiatrist). The Coroner's report records that he had been observed by the Prison Medical Support Officer to swallow his evening dose, 2 dilantin 100mg capsules, on 2 August, 1993. He placed his bedding on the floor as a precaution against falling if he experienced a convulsion during the night. At about 1am on the morning of the 3rd he did experience a convulsion, but told his cell mate soon afterwards that he was alright. He was discovered lying face down on his mattress by his cell mate at 7:00am, and could not be roused. It was found that he died between 2:00am and 7:00am.

Issues

Tests revealed that the 'dilantin' epilepsy medication was present in the bloodstream of the deceased at sub-therapeutic levels, which the pathologist found may have contributed to the death. The Coroner reported that he could make no conclusive finding as to whether this did contribute to his death. The Coroner satisfied himself that procedures had been changed since this death so that a record of the taking of medication by prisoners was now kept, rather than merely a record of what medication should have been taken.

Recommendations Nil

Royal Commission Recommendations Breached

R152g (viii) Protocols for care and management of Aboriginal prisoners in need of medication

Social Justice Commissioner

Comment

The medical officer's statement that the deceased took his medication on the evening before his death was accepted. A policy change after the death resulted in a formal system for notification of failure to take medication being introduced at the prison. However, a very ad hoc system for notifying medical personnel of refusal to take medication operated in 1993. The Medical Director at Pentridge stated that refusal to take heart disease, epilepsy or diabetes medication would normally have been notified to a medical practitioner, but did so in vague and imprecise terms. The deceased was vulnerable due to his psychiatric condition. Records indicated that two months previously he had told a nurse that he had not taken his epilepsy medication for a period of two weeks.

That formal procedures for notifying prison medical personnel of refusal to take medication be adopted at all custodial facilities in all jurisdictions.

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66VIC

Female, 42, died on 23rd September 1994
22-28 Fitzroy St, St Kilda, Victoria
Police Gunshot Wounds

Coronial Inquiry Deputy State Coroner Iain West

Finding handed down 23rd January 1996

Finding

The deceased died from multiple gunshot injuries to the chest [and back].

Summing-Up

Circumstances

The deceased suffered from psychiatric illness, and was highly intoxicated on the day she died. An autopsy revealed a blood alcohol reading of 0.3%, and therapeutic levels of sedative/hypnotic and anti-depressant medication. On two consecutive days she attended her clinic with a hatchet. On the second day she refused to relinquish the hatchet, and was told to leave the clinic. Her caseworker locked the clinic door and called police.

Police responded to a number of calls about a woman chopping up seats in the courtyard outside the clinic. On arrival the deceased was demanding entry, knocking on the wood-and-glass door with the blunt end of her hatchet. Damage to the door was minimal. Witnesses differed in their accounts, some afraid for the deceased, the witness with the clearest view remembering being afraid for the police. Police radioed base and were told (inaccurately) that backup was five seconds away. Police statements record putting their guns on the ground several times in an attempt to diffuse the situation, although this was not corroborated. According to the statement, the deceased raised the hatchet several times as if she were about to throw it. The police officer fired a 'warning shot' into the garden behind the deceased. The police statement records that the woman then challenged police to shoot her, raised the hatchet and began to run towards the officers. The officer stated that he instinctively fired five times 'without aiming' some two minutes and twenty seconds after the police first arrived.

Issues

The Coroner found that the officer fired in self-defence, and that police generally complied with their training. With the benefit of hindsight the police should have waited for backup, but the Coroner justified not waiting on the grounds that office workers could have been at risk if the deceased had used the hatchet on the door to gain entry. Police did not carry batons, as instructions required, but the Coroner found that the space was too restrictive for the batons to have been useful. The police pleaded the privilege against self-incrimination and their evidence at the inquest was not examined. No witnesses saw the incident, although one witness had stopped looking soon before the woman was shot.

The distance between the police officer and the deceased was found to be five metres, based on the position of the spent cartridges. This was further than the police account indicated. A bullet had lodged under the head of the tomahawk, corroborating the police account that it was raised. The space was too confined for the Coroner to accept that the deceased could run at police as claimed, but the Coroner was satisfied that the word 'run' was used to indicate sudden movement. The Coroner stated that no witness gave evidence that intoxication impeded her ability to move quickly. There was no corroboration of the account that the police officer had unfolded the legs from underneath the body of the deceased. The Coroner stated that his inference that the deceased was threatening was based on the fact of the shooting.

Three of the bullets entered the back of the deceased. The Coroner found that the first bullet spun the deceased around.

The Coroner did find that there was little training given to police in the use of firearms in the context of persons with psychiatric disabilities.

The Coroner was critical of the caseworker at the clinic for not communicating her specialist knowledge of the background of the deceased when she call the police. The emergency call was not recorded. Both the caseworker and the doctor at the clinic were criticised for not calling the Crisis Assessment Team.

Post death investigations were criticised. Police investigations were alleged to be by the homicide squad only, without active overseeing by the Internal Investigation Branch. The Coroner found that evidence on this point was insufficient, but he emphasised the need for an independent investigation. The Coroner stated that it was not appropriate that police had re-interviewed witnesses, causing their accounts to be amended. Finally, the police brief contained no details of the service history of the police involved.

The Coroner noted several changes in procedure since the death. 'Project Beacon' was introduced, a five-day training course for police to better deal with emotionally and psychiatrically disturbed people and concentrating on minimal use of force, with two additional training days each six months. Second, the introduction of expandable batons and evaluation of i) the use of capsicum spray and ii) recording of psychiatric histories of persons with a history of violence on the L.E.A.P. computer system. Third, clarification of types of incidents at which police would request the assistance of the Crisis Assessment Team. Fourth, the clinic which the deceased attended introduced protocols for cases in which police attendance is required.

Recommendations

i. That a critical evaluation be undertaken as to the merits of a firearm being the only effective weapon to counter an attack by an assailant using an edged weapon. While I am satisfied that such a response was appropriate in this case, I am concerned that there appears to be a universally held belief among operational members, that all edged weapons should be treated equally and that in defence from attack it is necessary to shoot until the threat is neutralised, regardless of the circumstances and in all probability having the effect of killing the assailant. As the inquest finding will be referred to the Ministerial Task Force on Police Shootings, it is requested that they ensure the identification of an appropriate independent investigator to make such evaluation, in conjunction with the Victorian Police Policy Unit or its nominee.

ii. That consideration be given to establishing within the Police Force, a specialist professional unit, appropriately trained, and equipped so that its members are in a position to take over from operational members during high risk crisis situations. The existing CAT teams are not in a position to meet this need, nor are the police negotiations from the Protective Services Group.
 
iii. That members attached to the LEAP Management Project remain vigilant in ensuring that as far as possible, the computer system maintains complete, accurate and up to date entries.
 
iv. That police members directly involved in a death resulting from contact between police and the public have their interview pursuant to par. 3.4 of the Standard Operating Procedures, either video or tape recorded. Just as the position held by a police Officer carries with it rights and privileges, it also carries the obligation of accountability. In being called to account the officer and the community are entitled to the most accurate record of explanation.
 
v. That when preparing the inquest brief involving a death resulting from contact between police and the public, investigators ensure appropriate background material concerning the member's police service is included in the brief.
 
vi. That the responsible officer from the Police Internal Investigation Department be vigilant in actively overseeing the investigation into a death resulting from contact between police and the public.
 
vii. Adopt the recommendation made by the State Coroner in previous inquests involving a death resulting from contact between police and the public, (the most recent being Skews and Crome 1304 and 1305/94) of the need for 'Critical Incident Review' of each incident. This is essential in order to assist the Police Force to identify potential areas for improvement and for the coronial investigation process.

Royal Commission Recommendations Breached

R35 Police investigations should: be approached on the basis that the death may be a homicide; inquire into the arrest or apprehension, lawfulness of custody and treatment and supervision of the deceased; and thoroughly examine the scene of death and forensic exhibits.

R36 Investigations of a death in custody should be structured to provide a thorough evidentiary basis for the coroner.

R162 Consideration of laws/instructions on use of firearms in arrest or preventing escape.

Social Justice Commissioner

Comment

There is no doubt that the situation was a difficult one. However, witnesses gave evidence that the six rounds were fired in quick succession, casting doubt on the description of the bullet fired into the garden behind the deceased as a 'warning shot.'

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ENDNOTES

1 The Victorian police reported the deceased to be Aboriginal. The coronial transcript contains conflicting evidence, and the Institute of Criminology is initiating investigations. The police had record of her being Aboriginal, so their procedures should reflect Royal Commission recommendations.

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A Report prepared by the Office of the Aboriginal and Torres Strait Islander Social Justice Commissioner

for the

Aboriginal and Torres Strait Islander Commission