Part E Profiles: Indigenous Deaths in Custody 1989 - 1996New South Wales
Coronial Inquiry Coroner B D Barrett at Townsville Coroner's Court Finding handed down 25 January 1990 Finding Hanging. The deceased met his death by his own willed actions. Summing up Circumstances of Death The deceased had been arrested for driving under the influence of alcohol and for driving while disqualified. He was placed in what the Coroner described as an enclosed cell, in which occupant vision is impossible, at around 3.00am and told he would remain there for a period of four hours. At approximately 4.40am, an officer discovered the deceased hanging from his cell door with pieces of shredded bedding material around his neck. Immediate action was taken to revive the deceased. Resuscitation was attempted by police and the ambulance officers who conveyed him to Townsville General Hospital, where further attempts to revive him were unsuccessful. The deceased was pronounced dead at 5.07am. Issues The deceased had previously been arrested 34 times for offences relating to drunkenness. He had a blood alcohol content of .21% on this occasion. Police reported that he was quiet and resigned after he was charged and told he would be detained for four hours. The Coroner found that the deceased 'on the evidence before [him], at no stage acted in a manner that aroused the attention of either officer'. He had requested and received a packet of cigarettes in the vicinity of 3.15am and was observed sitting on his bed smoking a cigarette at approximately 3.50am. Recommendations The Coroner recommended to the Commissioner for Police that video surveillance equipment be installed in all enclosed cells where occupant vision is impossible. He also pointed out that he made the same recommendation in February 1989 following a death in similar circumstances, but no action was taken. Royal Commission Recommendations R15 Responsibility of institutions to report on implementation of Coroner's recommendations within three months. (IR44) R16 Distribution of implementation reports on Coroner's recommendations. (IR44) R137 Police training and instructions to require checks of detainees; specified intervals between checks on the health and safety of detainees; monitoring/ checking procedures; more regular checks for detainees at risk. (IR15, 24) Social Justice Commissioner Comment The two page Coronial Report contained few details of the death. The finding that there was nothing to indicate the deceased was at risk seems to be based purely on police evidence. No details were given of Queensland's post-death investigation procedure, which was later to be criticised by the Royal Commission as overly dependent on police reports. There is no reference to an autopsy. There is no consideration of procedures for checking prisoners. There is no indication of whether the deceased was alone in the cell. The Royal Commission's Interim Report was released at around this time. It made numerous recommendations about the need for close surveillance of intoxicated persons and scrutinising of cells to remove items with the potential for self-harm. The Interim Report recommendations were not mentioned by the Coroner. The police sergeant conducting the investigation stated that he had never seen the Muirhead Interim Report. The Royal Commission (recommendation 125) advocated screening forms to elicit information on the detainee's psychological and medical condition, and careful assessment of these forms, which may have led to preventative measures being taken. The Coroner's recommendation that video surveillance equipment be installed should be considered in light of the Royal Commission's recommendation (139) that the use of electronic monitoring should not take the place of personal cell checks. Additional Royal Commission Recommendations Breached R7 Specific State/Territory Coroner for inquiries. (IR44) R8 Development of specific rules for inquiries and inquests. (IR44) R12 Legal requirement for Coroner to consider how the person was treated before death. (IR46) R13 Coroner to recommend ways to prevent further deaths. (IR44) R 35 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. (IR55) R95 Where motor vehicle offences are a major factor in imprisonment, programs to be consultatively developed to reduce incidence. R125 A screening form to be introduced for detainees on reception into police custody. R127f(i) Rules for care and management of Aboriginal prisoners at risk who are intoxicated. R165 Elimination/reduction of items with potential for self-harm.(IR23)
Coronial Inquiry Coroner D G Evans at Townsville Coroner's Court Finding handed down 11 December 1990. Finding The cause of death was acute and chronic alcoholism. Summing up Circumstances of Death The deceased was charged with public drunkenness at about 11.30am on the day of his death. He was unconscious at the time of arrest and had to be physically carried by two officers to the police van and the watch-house. At the watch-house he was placed in a coma position on the floor of the 'drunk cell' with a number of others arrested for intoxication. The charge was not read due to the deceased's unconscious state. Visual checks were made from outside the cell until about 3:45pm when a police officer entered the cell and found the deceased with no movement or pulse. Medical aid was not considered as police believed that life was already extinct. Issues The deceased was arrested after being observed lying beside the toilet in Hanran Park Townsville. This was the fourth day in a row he had been arrested for public drunkenness. When he was picked up by police he had apparently been unconscious for some time. There were black ants crawling over his clothes and hair. At the inquest all the police officers testified that they were unaware of the Interim Report recommendations concerning arrest and detention of persons suffering from severe intoxication. Recommendations 1. That medical assistance immediately be sought when persons who are known to be habitual drinkers are admitted to watch-houses; 2. That persons in charge or working in watch-houses receive adequate training so they are able to identify the differences between persons, asleep, unconscious, needing help, and when medical attention should be sought; 3. That police be given the same training; 4. That persons in charge of watch-houses make their own observations regarding health of prisoners; and 5. Implementation of Muirhead Report recommendation 13. Royal Commission Recommendations Breached R127f(i) Rules for care and management of Aboriginal prisoners at risk who are intoxicated. R133 Training of police officers to recognise those in distress or at risk. Such training to include general health status of Aboriginal population. More intensive training for officers whose work is cell guard duties only. (IR14) R135 People unconscious or not easily roused to be taken to a medical service, not a watch-house. (IR12) R136 People found unconscious or not easily roused to have immediate medical care. (IR13) R137 Police training and instructions to require checks of detainees; specified intervals between checks on the health and safety of detainees; monitoring/ checking procedures; more frequent checks if detainee at risk. (IR15) Social Justice Commissioner Comment This was the second death in less than one month in the Townsville Watch-house, both deaths raising issues relating to the detention of intoxicated persons. Unfortunately, the Coronial Report consisted of half a page of findings and another half page of recommendations. A different coroner was used, reducing the quality of scrutiny. This death raises the inappropriateness of criminal penalties for public drunkenness. It is totally unacceptable to arrest an unconscious person and leave them without care or supervision in a police cell. At the inquest it was stated that a newly issued police memorandum gave police the discretion to take intoxicated people to hospital. This does not give effect to Royal Commission recommendation 81 which calls for statutory duty based on legislation, for police, where possible, to use alternatives to police cells for intoxicated persons. The testimony of police in later cases indicates that, in any event, they are unaware of new guidelines or standing orders and believe that under Queensland legislation they must arrest intoxicated persons and take them to police cells. Training police officers to handle or detect the health risks facing intoxicated persons is especially important given the Queensland Government's inaction on decriminalising public drunkenness and the lack of alternatives to police custody. A medical assessment screening form completed prior to placement in a cell, as recommended by the Royal Commission (Recommendation 125), would likely have alerted police to the inappropriateness of their actions. The case also illustrates the importance of having a medical presence at watch-houses (Recommendation 127). Other Royal Commission Recommendations Breached R7 Specific State/Territory Coroner for inquiries. (IR44) R8 Development of specific rules for inquiries and inquests. (IR44) R12 Legal requirement for Coroner to consider how the person was treated before death. (IR46) 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. (IR50,51,55) 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) R125 Screening form to be routine part of reception into custody and to be evaluated. R127a Regular medical presence in watch-houses in capital cities and other major centres. R214 Support for community policing with involvement of Aboriginal communities and organisations in developing procedures in areas where Aboriginal people live or gather.
Coronial Inquiry Not conducted Social Justice Commissioner Cause of Death The cause of death was massive internal haemorrhage and stab wounds to chest and neck. 1 Circumstances of death Unknown Issues The decision by the Coroner not to carry out an inquest is disturbing. The fact that a criminal trial was to follow for an offence relating to the death in custody should not exclude the role of the Coroner. Unlike the court, the Coroner can dispel suspicions and look at broader issues underlying the deceased's arrest and imprisonment. The Coroner can examine the adequacy of structures and procedures in place to supervise prisoners. The Coroner can look at organisational matters which may have contributed to the death, and ways of preventing similar deaths. A full inquest, which looks at the quality of the care and supervision of the deceased prior to death, should be held. Royal Commission Recommendations R11 All deaths in custody be required by law to be the subject of a coronial inquiry culminating in a formal inquest. (IR45) R12 Coroners to investigate not only cause and circumstances of death, but also quality of care, treatment and supervision of the deceased prior to death. (IR46)
Coronial Inquiry Coroner K P Lynn at Rockhampton Coroner's Court Finding handed down on 5 November 1990 Finding The death was due to hanging, and there were no suspicious circumstances surrounding the death of the deceased. Summing Up Circumstances of death The deceased was serving sentences for offences committed against the Prisons Act whilst in custody. He had been confined to a detention unit after a fight with a prison guard. He reportedly refused to answer when challenged by the guard about being handed something by another person. The prison guard then followed the deceased into the gymnasium where heated words were exchanged. The deceased was then found to have approached [the guard] and punched him in the face. After a struggle, the deceased was restrained by a number of officers and conveyed to the chief's office still struggling. He was subsequently handcuffed and taken to the detention unit. That afternoon the deceased became agitated because he believed he saw a prison officer spitting in his food. He was given unspecified medication by a prison officer serving as a medical orderly. He was last spoken to by a fellow inmate at 8pm. During a head count at about 11:15pm the deceased was observed through the cell door, but a significant portion of his body was obscured by a towel hanging over the grill on the door. He was observed in the same position some three hours later. Suspicions were raised, but cell keys were not carried by prison officers during head counts and time was lost before his cell door could be opened. When officers gained access they found that one end of a piece of a sheet was knotted around his neck with the other end fastened to a mesh grill at the front of the cell. The deceased was pronounced dead at 4.05am. Issues The deceased had a history of hypersensitivity. The Coronial report indicated that he had recently been prescribed medication for depression, but did not take it. The Coroner found that he clearly had difficulty accepting the restraints imposed by life in prison. He had charges relating to over sixty offences, including assault occasioning bodily harm, street offences, unlawful use of a motor vehicle and break and enter. During a period of incarceration from 1987 to 28 January 1990, the deceased was breached 20 times for offences under the Prisons Act. The deceased had been seen by a psychologist several times in the two months preceding his death. Initially the deceased was considered at risk and referred to a psychiatrist. There was no indication that he actually saw a psychiatrist. The Coroner asserted the psychologist reported that on 22 March the deceased 'appeared to have settled down considerably since the last time I saw him, at this time I did not have any concern that he was in any way contemplating suicide and I did not consider that psychiatric help was needed'. Recommendations Nil Royal Commission Recommendations Breached Nil Social Justice Commissioner Comment The coronial findings were cursory, consisting of three pages with no recommendations despite revealing questionable practices, such as prison officers not carrying keys during head counts. The Coroner was a layperson and not a magistrate. The findings did not consider possible provocation by a prison guard who had fought with the deceased. The administrator of the Rockhampton Aboriginal Legal Service told journalists at the time of the death that inmates at the prison were discontent and had reported 'intimidation, harassment and unfair disciplinary action from prison officers, including the denial of privileges for petty offences.' 2 The number of offences against the Prisons Act might be seen to lend support to the claim. The recommendation that imprisonment be a last resort would seem to conflict with the extended detention for summary offences under the Prisons Act (R92). While this assessment may not have been correct, public suspicions of poor custodial care should be dispelled by a coronial inquest. Remarks indicating the deceased was not at risk of suicide, although quoted in the past tense, were represented in the Coroners findings as being from records made on the day of the psychologist's last examination. The deceased had been involved in a violent incident on the day he died, and notes on the file from the psychologist indicated that he was hypersensitive and would have reacted badly to violence. This file note should have been part of a consideration of precautions for assessing his risk status before placing him alone in detention in a cell. Instead, he was seen by a prison officer serving as a medical orderly. No special precautions were taken, and the deceased had been three hours without a cell check when he was found. The earlier cell check was seemingly made with such lack of attention that it failed to establish that the deceased was already hanging. There seems to have been no Aboriginal welfare officer at the prison. This was the first of two deaths within twenty-four hours in the Rockhampton Correctional Centre. Additional Royal Commission Recommendations Breached
R7 Specific State/Territory Coroner for inquiries. (IR44) R9 Stipendiary Magistrate or more senior person to be Coroner. (IR44) R12 Coroner be required by law to investigate quality of custodial care prior to death. (IR46) R13 Coroner to make recommendations to prevent further deaths. (IR44) R92 Legislative enactment of the principle that imprisonment be a last resort. R152f Guidelines for exchange of information between medical and prison services. (IR37) R152g(iv) Protocols for the management of prisoners who are at risk of self-harm. R152g(v) Protocols for the management of prisoners who are angry, aggressive or otherwise disturbed. R152g(vi) Protocols for the management of prisoners suffering mental illness. R154a Training of Prison Medical Services staff to ensure they understand Aboriginal health issues. R165 Elimination/reduction of items with potential for self-harm. R174 Aboriginal Welfare Workers in prisons.
Coronial Inquiry K P Lynn at Rockhampton Coroner's Court Finding handed on 2 November 1991 Finding The cause of death was hanging. Summing up Circumstances of Death The deceased hanged himself in his cell the night after another Aboriginal inmate was found hanged in the Etna Creek Prison (now Rockhampton Correctional Centre). The first death resulted in unrest and anger from some inmates, including the deceased. His file was already marked 'suicidal.' Prison officers observed the deceased singing and playing his guitar with other inmates in the latter part of the evening. Although he spoke about his lack of fear of suicide, the Coroner found that other prisoners had no suspicions that the deceased would actually commit suicide. The block officer had been told the deceased was unsettled and should be checked regularly. These instructions were not passed on to the relief, however, who took over at about 9.30pm. No further checks were then made for nearly two hours. At around 11.10pm, during a head count, the deceased was seen in a sitting position, his back against the rear wall of the cell. His body was next to the toilet bowl with his heels and calves touching the ground and the rest of his body hanging suspended from a piece of white material attached to the lower centre louvre at the rear of cell. He had also cut his wrist, and there was a large pool of blood on the floor. After obtaining the keys to the cell, officers undid the noose and checked the deceased for signs of life. Although at first it was thought there was a small pulse in the right wrist, further checks were unable to detect any vital signs. Ambulance officers and the GMO attended the deceased and he was found to be dead. Issues The Coroner stated that the correctional centre did not have a formulated plan for dealing with inmates suspected of being suicidal. The Coroner found that the deceased's history of offences against prison rules and regulations showed he was an inmate who had difficulty coping with prison life. As well as a 12 month sentence for break and enter, the deceased had received a 3 month sentence, three days prior to his death, for damaging government property in a suicide attempt. He had been arrested for drunkenness, and knotted strips of blanket were discovered during a check of his police cell. The Longreach District Officer submitted a report to Rockhampton Prison following this incident, stating that the deceased was a potential suicide risk. A government medical officer (GMO) at Longreach later offered a contrary opinion, advising that there was very little chance of a repeat attempt. On admission to the Etna Creek facility, another GMO referred the deceased to a psychiatrist, believing 'he was more depressed than you would expect an inmate to be on admission. ' Following a brief examination, the psychiatrist found no significant risk of suicide, although he prescribed a relaxant medication three days later. A letter from the psychiatrist, received by the Prison after the death, stated that the deceased 'retained a tendency [to be a danger to himself] and should be monitored if his circumstances deteriorate'. The deceased's file, the chief's log and the location board were marked suicidal but no oral or written instructions were given about additional monitoring or other procedures, such as removal of hanging points. After the suicide the previous night, the superintendent spoke collectively to the inmates and individually to the deceased, and asked another inmate to keep an eye on him. He also requested the block officer to keep a close watch on the deceased. There were 'no specific additional instructions given regarding the deceased, the superintendent being of the opinion that officers were already aware of the deceased's tendencies'. The Coroner noted several deficiencies in prison procedure in his rider. Two hours elapsed between cell checks, although officers had expressed the opinion that half-hourly to hourly checks were appropriate depending on the level of concern about the inmate. Both the GMO and the psychiatrist stated that they made comments about monitoring the deceased that were not included in the inmate's medical records. Recommendations The Coroner made a number of recommendations in a rider forwarded to the Attorney General, including: 1. That 'a conference be held between medical and custodial staff to formulate a specific plan of action with respect to the supervision of each at risk inmate'; 2. That 'specific instructions be formulated to cover exactly what supervision and action is progressively required in order that officers clearly understand what they should be doing by way of monitoring'; 3. That if concern is felt there should be a practice of keeping an eye on the inmate, with hourly or half hourly checks progressing through to one-on-one supervision. Royal Commission Recommendations R123 Instructions on care of persons in custody to be known, understood, enforceable and publicly available. R155 Training of prison officers to include Aboriginal health, information, risk assessment and appropriate emergency action to be taken. (IR28) R152f Guidelines for exchange of information between medical and prison services. R152g(iv) Protocols for care and management of Aboriginal prisoners who are at risk of self-harm. Social Justice Commissioner Comment This death and the previous death raise questions which the Coroner did not address. Both prisoners had records of frequent breaches of discipline. As noted in relation to the previous death, the administrator of the Rockhampton Aboriginal Legal Service had told journalists at the time of the death that inmates at the prison were discontent and had reported 'intimidation, harassment and unfair disciplinary action from prison officers, including the denial of privileges for petty offences'. Again, the accuracy or otherwise of this claim should have been addressed. The three month prison sentence for damaging a blanket in police cells in the course of a suicide attempt is indefensible. Charges should not have been laid at all, but to resort to imprisonment for such a minor offence, especially while the Royal Commission was proceeding, is extraordinary. The Coroner emphasised the complete lack of any procedures to accompany the 'at risk' classification. It was found at the inquest months later that there was no evidence of procedures for suicidal inmates. The deaths had not provoked a consideration of procedures to reduce risks of similar incidents in the future. The Royal Commission Interim Report, which had been released at the time of the Inquest, declared that 'the dangers of placing emotionally disturbed... prisoners in isolation for whatever cause without a full measure of surveillance cannot be over-emphasised. The young appear particularly vulnerable [and] it is no longer acceptable to claim that close surveillance is not practicable. The means must be found'. 3 Additional Royal Commission Recommendations Breached R7 Specific State/Territory Coroner for inquiries. (IR44) R9 Stipendiary Magistrate or more senior person to be Coroner.(IR44) R12 Legal requirement for Coroner to consider how the person was treated before death. (IR46) R92 Legislation to ensure imprisonment is used as sanction of last resort. (IR1) R124 Debriefing procedures to follow incidents to reduce future risks. R164 Care in laying charges in cases of self-inflicted harm with preferably no charges laid. R165 Elimination / reduction of items with potential for self-harm. R173 Shared accommodation facilities.
Coronial Inquiry Coroner Irvine Killeen, at Mornington Island, Townsville and Brisbane Finding handed down 20 November 1991. Findings The deceased died from raised intracranial pressure due to (or as a consequence of) traumatic brain damage. The failure by the various members of the Police Service or Aboriginal Police to adequately care for and supervise the deceased whilst in police custody did not constitute negligence to a criminal degree. Summing Up Circumstances of Death The deceased was found lying unconscious beside the road by two Aboriginal community policemen on patrol. His condition, previous arrests for drunkenness and apparent lack of signs of serious injury led them to assume he was only affected by excessive alcohol consumption. Other prisoners gave evidence that they also thought the deceased was 'drunk and asleep'. His condition was not noticed the following morning when the other prisoners were released. Later in the morning he was unable to be woken by an Aboriginal police aide. He was transferred to Townsville General Hospital where attempts to revive him were unsuccessful. It was accepted that the injury had been caused by a blow or number of blows to the head inflicted by one or more of a named group of children when the deceased was lying drunk in the grass. No charges were laid. Further pathological evidence revealed a previous serious head injury probably inflicted some two weeks earlier, which would have predisposed the deceased to the fatality of the later attack. Issues Evidence tendered that the Aboriginal community policemen had handled the deceased roughly and caused the brain injury were denied by both. The delay in the medical examination and treatment of the deceased following the assault may have contributed to his death, but no person was found to have suspected injury requiring medical attention. The Coroner was particularly scathing in his criticism of the circumstances of death, and made a number of findings including: That there was a failure on the part of all individuals on duty during the incarceration of the deceased at the police watch-house to properly perform their custodial duty and responsibility, and that none of them had any training to enable them to distinguish intoxification from more threatening conditions. The conduct of police in leaving Aboriginal community police aides unsupervised and in charge of people in police custody was inappropriate. The turnover of Aboriginal Police Aides indicated a problem with their employment conditions. That driving past the watch-house and observing the cells by shining the headlights through the front screen mesh was improper and inadequate and not in accordance with General Instructions and the cursory and fleeting inspections of prisoners were infrequent and not in accordance with instructions. The arrest of the deceased was also found to be 'unlawful' as the community police aides have no authority under Council By-laws to make arrests on behalf of police. The absence of means for prisoners to raise the alarm or contact police in emergencies was also raised, although no other prisoner noticed the condition of the deceased and he had been unconscious before his arrest. 4 Recommendations The Coroner made recommendations relating to his findings including: 1. The Duty of Police Officers towards People in Custody i. The Police Commissioner is to ensure by means of training or General Instruction that the Recommendations of the Royal Commission are conveyed to and are fully understood by all members of the Police Service. ii. All police officers shall comply with the General Instructions regarding watch-house procedures. iii. All Watch-house Keepers and Officers in Charge of small stations shall ensure strict adherence to the General Instructions regarding watch-house procedures. iv. All police officers to be made fully aware of the duty of care owed to persons in police custody. 2. Appointment and Training of Aboriginal Policemen i. It is to be acknowledged as important that Aboriginal Policemen be appointed to assist members of the Police service in policing Aboriginal communities. ii. The Council, as employer of Aboriginal policemen, should increase the monetary or other benefits to Aboriginal Policemen as an incentive and inducement to attract and keep suitable persons as Aboriginal Policemen. An alternative is for the Police Service to employ or pay a retainer fee to such persons. iii. An Aboriginal Policeman shall receive proper formal training prior to commencement of duty. iv. An Aboriginal Policeman shall not be placed in charge of a police watch-house or left unsupervised excepting in emergency situations. 3. Arrest for Drunkenness i. The Council should amend its by-laws as a matter of urgency to authorise Aboriginal Policemen to arrest or apprehend persons for drunkenness. ii. All unconscious persons, through intoxification or otherwise, apprehended or found by Police shall be examined by a suitable trained medical person preferably a Doctor. iii. The practice of the division or separation of the functions and operations of the members of the Police Service and the Aboriginal Policemen on Mornington Island should cease. It is more appropriate that an Aboriginal Policeman work alongside a member of the Police service particularly on community patrol. iv. The State Government should consider, as a matter of urgency, implementation of legislation to decriminalise drunkenness. 4. Facilities for the Care of Drunken Persons i. Although not a relevant factor in the death, the police watch-house does not provide a safe custodial environment. It is in a poor condition, is not conducive towards proper supervision or care of prisoners, it is isolated from the Police Station, it does not provide an alarm or means for a person in custody to contact the person in charge of the watch-house. The State Government should consider the immediate replacement of this watch-house. ii. As most persons are arrested for drunkenness and placed in police custody for their own safety and protection, it is recommended that a diversionary facility be established on Mornington Island to accommodate, care for and treat persons affected by excessive alcohol consumption. Royal Commission Recommendations Breached IR34 Aboriginal police aides scheme be re-examined to ensure that role is not merely to assist police in everyday duties but to be a link between the Aboriginal community and police R79 Abolition of the 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) R1 Police and custodial authorities to recognise their legal duty of care to persons in their custody. R123 Instructions on care of persons in custody to be known, understood, enforceable and publicly available. R127a Readily available medical assistance in centres other than capital cities. R127f(i) Rules for care and management of Aboriginal prisoners at risk because they are intoxicated. (IR15) R133 Training of police officers to recognise those in distress or at risk. (IR14) R135 People unconscious or not easily roused to be taken to a medical service, not a watch-house. (IR12) R136 People found unconscious or not easily roused to have immediate medical care. (IR13) R137 Police training and instructions to require checks of detainees; specified intervals between checks on the health and safety of detainees; monitoring/checking procedures (IR15). R141 No-one to be detained without care and supervision. R232 Urgent review of Queensland community police and the powers of community councils concerning them. (IR34) Social Justice Commissioner Comments The post-death investigation was deficient in a number of respects. Police gave evidence by way of statements rather than records of interview. The police report was only made available to the solicitor for the next of kin hours before the inquest. Although described as a conscientious attempt, it did not investigate whether there was compliance with general instructions in the police manual, whether there was a suitable discharge of the duty of care, or whether there were systemic problems in police procedures which should be rectified to prevent further deaths. The standard and quality of policing on Mornington Island showed profound deficiencies. The Human Rights and Equal Opportunity Commission's Report on Mornington Island recently followed-up problems with the administration of justice on the Island. The Watch-house has been replaced, but: (a) the Queensland Police Service failed to consult with the community about the new watch-house; (b) there is a failure to separate clearly the court function from the police function in the new police complex; and (c) the expense ($2.8M) and size of the new complex is an inappropriate response to the needs of the community, given the lack of a sobering-up centre on the Island. There continues to be a failure to ensure that Aboriginal communities have formal and ongoing participation in the selection of police officers in their communities. 5 The need is apparent for screening procedures in order to assess the physical and mental health of detainees before they are placed in cells. If such a procedure were in place (see Recommendations 125), it is likely the deceased would not have been placed in a cell. Other Royal Commission Recommendations breached R7 Specific State/Territory Coroner for inquiries. (IR44) R36 Police investigations should be structured to provide a sound evidentiary base for the coroner. R125 Screening form to be routine part of reception into custody and to be evaluated.
Coronial Inquiry Coroner H T Spicer Finding The cause of death was hanging, with no evidence of criminality against any person. Summing up Circumstances of Death The deceased was HIV positive, and as a result was placed in segregation at Lotus Glen Prison in compliance with Correctional Services policy and directives from the Commission's Director of Medical Services. On 12 January 1991 the deceased was found hanging in his cell by staff delivering the evening meal at approximately 5.50pm. Issues The deceased, from Palm Island, had been diagnosed as HIV positive at sixteen, and was the first Aboriginal prisoner in Queensland with the virus. On July 25, 1990 he was found guilty before Judge Wylie in Townsville District Court of wilful exposure, two charges of assaulting police, wilful damage to property and break and enter. The circumstances of the offence included smearing his excrement in the face of a police officer. He made an early plea of guilty, had no previous convictions and expressed remorse, but was sentenced to nearly three years in prison. He was only expected to live for two years. Deterrence of the threat of AIDS in the course of criminal activity was held to outweigh the personal circumstances of the offender in sentencing. In August 1990, a letter was signed by the nursing staff and sent to the Manager of Operations outlining concerns for the physical and mental well-being of the deceased and another prisoner in isolation. In response, visits by an Aboriginal Official Prison Visitor and regular trips to Cairns to see an AIDS counsellor were arranged. The Coroner found that the main contributing factors leading up to the death appeared to be the fact he was HIV positive; his isolation; his sentence and loss of appeal against sentence; the rejection of his application for a pardon; the rejection of his application for parole; the inadequacy of family support; and, the termination of counselling by a volunteer counsellor with the Queensland AIDS Council who was also HIV positive. A directive from an officer of the Queensland Health Department, who was apparently acting on advice from an Aboriginal person, had the effect of cancelling the visits from the counsellor. This 'misunderstanding' caused considerable distress to the deceased. It appears the deceased was fairly well provided for in terms of material comforts and access to counsellors and prison staff. However 'his conditions lent towards isolation from 6pm until morning' (other prisoners could mix with each other until 9.30pm). The last visit by any member of the family was some five months before his death. His mother could only afford to make the 350km trip to visit the deceased once in the year prior to his death. That trip was paid for by a newspaper. Recommendations 1. That on reception at a Correctional Centre, there be an immediate in-depth psychiatric and physiological assessment of the person admitted, particularly in cases of: (a) AIDS sufferers (b) Suicide risks (c) Aboriginal cultural backgrounds. It is extremely important in relation to Aboriginal people that a detailed history of family background be obtained including cultural needs and geographical position of the relatives. 2. That Aboriginal support groups assist in maintaining close family relationships, including funding and transport, especially where the inmate is geographically separated by distance from family and relatives. 3. That ongoing tuition be given to correctional staff, especially to address the problems of inmates with AIDS and inmates of Aboriginal culture. 4. That in situations such as arose in this case [and] especially in AIDS cases, [that] liaison be established and maintained amongst all parties concerned. Royal Commission Recommendations R152g(vii) Protocols for specific action to be taken in the case of serious medical conditions. R154a Training of Prison Medical Services staff to ensure they understand Aboriginal health issues. (IR28) R155 Training of prison officers to include Aboriginal health, information, risk assessment and appropriate emergency action. (IR28) R168 Prisoner to be incarcerated near family. R169 Financial assistance for visits where a prisoner is not incarcerated near family. Social Justice Commissioner Comment The Coroner's recommendations show a degree of insight and sensitivity to the needs of Aboriginal inmates, particularly those in the deceased's situation. It is particularly welcoming to see issues such as geographical location of family and Aboriginal culture being included in admission assessments. His recommendation that 'Aboriginal support groups assist in maintaining' family ties should be read as recommending adequate funding and resources to carry out this role. The case begs the question of why police engaged with the deceased other than with the care needed when any person is displaying signs of mental illness. He was obviously disturbed. He had smeared excrement on himself and was masturbating on a veranda when police approached him. He was convicted of wilful exposure, two charges of assaulting police, wilful damage to property and break and enter. The circumstances of the offence included smearing some of the excrement already on his body in the face of a police officer - not a premeditated act. He made an early plea of guilty, had no previous convictions and expressed remorse, but was sentenced to nearly three years in prison. He was only expected to live for two years. His condition placed him under great mental stress. A punishment more humane than effective life imprisonment could have been arranged for the dying juvenile. The principle of imprisonment as a last resort (Royal Commission recommendation 92) should have applied. Recommendation 173, that Aboriginal prisoners should not be put in isolation or segregated from other prisoners, is also relevant. Prison officials informed the Coroner that other prisoners would not be disposed to share with the deceased. An Aboriginal woman who visited the prison shortly after the death reported that inmates told her they would have had no problems being housed with the deceased. In refusing to allow the appeal against the severity of the sentence, McPherson J of the Queensland Court of Appeal referred to the deceased's condition with what the authors to the predecessor to this study referred to as 'callous and offensive brevity': 6 We understand that he has also been informed at the beginning of 1990 that he had the HIV condition and that he will die from it. He is a person of low intelligence. Additional Royal Commission Recommendations Breached R7 Specific State/Territory Coroner for inquiries. (IR44) R92 Imprisonment as a last resort. (IR1) R96 Training of judicial and court officers in Aboriginal society, history and culture. R181 Segregation and isolation of Aboriginal prisoners to be avoided. Minimum standards for segregation including fresh air, lighting, daily exercise, adequate clothing and heating, adequate food, water and sanitation facilities and some access to visitors. R183 Commitment and assistance to operation of Aboriginal support groups within institutions. R242 Police to use cautions rather than arrest, or summons or attendance notice, preferably with guardian present.
Coronial Inquiry Ivan Smith SM at Rockhampton Coroner's Court Finding handed down 15 January 1992 Finding The cause of death was epilepsy due to or as a consequence of alcoholism. Summing up Circumstances of Death The deceased had been arrested for an unpaid fine and for an obscene language charge which, as noted by the Coroner, had a default period of two days imprisonment for the sixty dollar fine. He was placed in a cell at approximately 9:30am on 1 May 1991. He had apparently been involved in a fight. He had a noticeable facial injury. The deceased apparently refused medical assistance offered by police. The deceased was found dead almost 24 hours later. Rigor mortis had set in. He had not risen out of bed in that time. Issues The Coroner was highly critical of the claim by the Police Service that relevant recommendations had been implemented, saying that 'the use of the word "implemented" seems entirely inappropriate as I understand the meaning of the word. The facts are that, at least in Rockhampton Watch-house, a number of those recommendations have not been implemented'. The Coroner found that the deceased should have been required to undergo a medical assessment on admission, particularly when it was known that he suffered from epilepsy and alcoholism, had a facial injury and was sick in the cell. He found that the death highlighted and emphasised the current deficiencies in the present watch-house system and the shortcomings and inadequacies of the present standing orders. The Coroner found that the deceased had been checked regularly by glancing through the cell door. Recommendations 1. That a copy of this decision and recommendations go to the Assistant Commissioner, Rockhampton Police Region. 2. When it is apparent that a detainee is injured, particularly a possible serious head or facial injury, a medical practitioner should be made available to assess the nature and extent of the injury whether the detainee consents to such an examination or not. 3. Where it is apparent that a detainee suffers from epilepsy or similar illness, or a combination of alcoholism and epilepsy or a similar illness, whether or not on medication, such person shall not be detained overnight or for any period during the day in excess of two hours without there being a medical assessment of risk. 4. That the standing orders at Rockhampton Watch-house should be totally revised and urgently updated to include the recommendations of the Royal Commission. 5. That police officers, especially those who work in the watch-house, are made thoroughly aware of the revised and updated standing orders rather than simply shown a list of such orders on the watch-house wall on commencing duty. 6. That, where possible, young and very inexperienced officers should not be rostered on the night shift at the watch-house, a more dangerous time for certain detainees calling for a certain maturity, common sense and experience. Royal Commission Recommendations Breached R122 Police and custodial authorities to recognise duty of care. R123 Instructions on care of persons in custody to be known, understood, enforceable and publicly available. R125 Screening form to be routine part of reception into custody and to be evaluated. R127a Regular medical presence in watch-houses in capital cities and other major centres. R127f(i) Rules for care and management of Aboriginal prisoners at risk because they are intoxicated. R127f(ii) Rules for care and management of Aboriginal prisoners at risk because they suffer illnesses. R131 Police recording of information affecting risk. R133 Training of police officers to recognise those in distress or at risk. R138 Police instructions to require recording of information relevant to well-being of detainees. R161 Instructions to seek immediate medical care if doubts about prisoner's condition. Social Justice Commissioner Comment Although the Coroner appeared to accept police statements that the deceased had been checked regularly by police looking through the cell door, the findings are not convincing. Rigor mortis had set in by the morning of 2 May. That he had not arisen out of bed in almost 24 hours casts doubt on statements that checks took place. If checks took place, they were clearly not adequate for a person in his condition. There was no reference in the findings to written records of the checks. The Coroner expressly stated that the majority of custodial health and safety recommendations relevant to this death were not implemented at the Rockhampton Watch-house. Unfortunately, the findings did not contain enough information to determine the full extent of the breaches. The Coroner did not comment on other significant aspects of the case. The deceased was arrested on a warrant for a charge of obscene language, a trivial offence specifically singled out for criticism by the Royal Commission. The Coroner should have examined the lawfulness of this arrest as the charge had not yet been proven in court (Recommendation 35c). As there is no indication that he was brought before a magistrate during the day of 1 May, it appears that the deceased was to serve an automatic two day period of imprisonment for an outstanding warrant for an obscene language charge, Police demonstrated a lack of understanding of what a duty of care entails. The deceased had a known history of epilepsy and drunkenness and an obvious facial injury, and yet police did not realise that they, by deciding to arrest and effectively exclude other avenues of medical assistance, assumed a common law duty of care (as well as any statutory duty on them to care for prisoners). Other Royal Commission Recommendations Breached R7 Specific State/Territory Coroner for inquiries. R12 Legal requirement for Coroner to consider how the person was treated before death. R13 Coroner to recommend ways to prevent further deaths. R35 Police investigations should inquire into the arrest or apprehension, lawfulness of custody. R86 Offensive language during police initiated action not to be basis for arrest and charge. R87 Police to apply arrest as a final sanction. R92 Imprisonment as a last resort. R121 Imprisonment not be automatically imposed for default on fine payments. Alternative sanctions be considered, and a statutory duty to consider capacity to pay. R137 Training of police to ensure regular, careful and thorough checks of all detainees, with more regular checks for detainees at risk.
Coronial Inquiry Coroner Fisher Finding handed down 2 November 1994. Finding Having remained unconscious since 5 October 1991, the deceased suffered respiratory failure as a result of a cerebral necrosis as a consequence of head injury on 14 November 1991. No person is committed for trial for an offence in relation to this death. Summing up Circumstances of Death The deceased was arrested on 4 October 1991 after police were called to an argument at her home. The Coroner stated a knife and a small child were involved. On arrival, it was established that the deceased was very intoxicated. After being asked by the other occupants of the house to leave and refusing, the deceased was physically conveyed outside the house and placed near the rear of the police vehicle parked outside. She was then arrested for being found drunk in a public place. The deceased was taken to the watch-house. The Coroner found that she was awake but drunk. Periodic checks were made during the course of the shift and she was found to be asleep and snoring. The following morning the deceased was observed frothing at the mouth by a police officer checking on overnight prisoners. Attempts were made to wake her, but were unsuccessful. She was then conveyed to the Palm Island Hospital and found by the medical superintendent to be comatose. The deceased was conveyed to Townsville General Hospital where she was diagnosed as having had a large left frontoparietal subdural haematoma. An operation was performed to remove the haematoma, but the deceased remained in a comatose state until her death on 14 November 1991. Issues There had been a struggle in the course of the arrest. The Coroner reported that no injuries of any kind were noted on the deceased, either by the police or by medical authorities. The Coroner noted that the creation of detoxification centres, which are being or are to be established, will significantly assist what is said to be a very difficult, if not impossible, task in relation to the assessment of the condition of drunken persons. Recommendations 1. That extra copies of form 4 be prepared for inclusion with any samples forwarded for pathological examination. 7 2. A copy of this transcript of proceedings be provided to the Commissioner of Police for examination and further dissemination of any information or instructions, as he may deem necessary, regarding apprehension and care of drunken persons. Royal Commission Recommendations R133 Training of police officers to recognise those in distress or a risk. Social Justice Commissioner Comment The Inquest was not completed until some three years after the death. Witnesses had made statements to the Townsville Legal Service that the deceased was 'carried and thrown' by two policemen into the back of the police vehicle. These were rejected by the Coroner, who listed the cause of death as cerebral necrosis in his findings without any explanation of the head injury which the post mortem examination listed as a cause of death. The legality of the arrest is questionable, although the Coroner made no comment. The police had conveyed the deceased from a private home and charged her with 'being drunk in a public place'. The coronial findings did not adequately address the issue of the resistance to police by the deceased when she was physically restrained and taken out to stand beside the police van. The Coroner relied on the evidence of the police and medical staff for the finding that there was no mistreatment of the deceased. The evidence seems to have come solely from the Police Report. The allegation was aimed at the police. The deceased remained in a coma for nearly a month after the arrest. Any injuries caused may have had time to heal before an autopsy was carried out. Medical staff may not have been aware of the allegations. Part of the function of an Inquest is to dispel public suspicion of misconduct. The Coroner failed to do so in this case. This investigation highlights the problems associated with the ad hoc nature of the Coronial system in Queensland. Lengthy delays result from co-ordination required between police investigators, forensic pathologists and Coronial staff. A centralised system with specialist staff, as recommended by the Royal Commission, would alleviate some of the problems. Legislation should be enacted, urgently, for a centralised and independent investigation process to bring Queensland into line with other states. Additional Royal Commission Recommendations Breached R7 Specific State/Territory Coroner for inquiries. R8 Development of specific rules for inquiries and inquests. R12 Legal requirement for Coroner to consider how the person was treated before death. R13 Coroner to recommend ways to prevent further deaths. 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. R60 Police services to eliminate rough treatment or abuse of Aboriginal prisoners. R79 Abolition of offence of public drunkenness. R80 Adequately funded facilities for intoxicated persons to accompany abolition of this offence. R81 Statutory duty to consider and use alternatives to police detention of intoxicated persons. R125 Completion of a screening form prior to placement in a cell. R135 Intoxicated or semi-rousable people to be given medical attention, not conveyed to police cells. R136 People found unconscious or not easily roused to have immediate medical care. R137 More frequent checks of prisoners at risk.
Coronial Inquiry Coroner Gary Casey SM at the Brisbane Coroner's Court Finding handed down 4 June 1993 Findings The Coroner found that the deceased died in cell 3, unit 2C of the Sir David Longlands Correctional Centre of hanging. There was no evidence of a criminal nature that may be imputed to any person, and evidence adduced supports the inevitable conclusion that the deceased was a potential risk of committing suicide. Summing Up Circumstances of Death The deceased was sentenced to six months imprisonment for motor vehicle offences in August 1991. During this term he received three additional six month sentences for offences committed prior to his incarceration. Although a juvenile, he asked to be treated as an adult prisoner. He was moved to Boggo Road, and when it closed, to Sir David Longlands Prison. His medical history form at Boggo Road indicated that he had previously attempted suicide. No procedures were put in place as a result. He was withdrawing from amphetamine abuse, had migraines and had lost weight. His mother had expressed concern to corrections employees about the drugs he was receiving in prison to replace his dependancy (for example, valium, neulactil). He had failed to recognise her during a visit, and she described him as heavily sedated, his face swollen and puffy. The senior psychologist at the prison described the deceased as severely depressed, but refused his request for anger management counselling. Concerned by his suicidal tendencies, his Unit Manager referred him to the Nursing Manager in September. His dose of valium was increased as a result. He was then given diazepam after partially destroying his cell, and a valium after complaining of claustrophobia in October. On December 11 the deceased cut both his wrists after a disagreement with his girlfriend. He was returned to his cell after 24 hours observation. On December 16 and 17 he was locked in his cell for 48 hours, during which time he again destroyed the cell. A doctor saw him on December 17 and prescribed medication for his 'acutely disturbed' state. On December 18 he was moved from the youthful offender unit into the mainstream adult prison. The deceased's girlfriend had ended their relationship on night of his death. Corrective Services personnel notified a nurse of emotional disturbance. He was given mogadon and received verbal re-assurance from the nurse and another adult inmate. He was then locked in for the night in accordance with routine prison practice. He was checked cursorily by officers at lock down, around 8:30pm, and not checked until around 10.50pm when his body was found hanging by a bed sheet suspended from the bar of the window above the cell door Despite resuscitation attempts by Queensland Ambulance Service personnel, the deceased failed to respond and life was subsequently pronounced extinct at 11:45pm. Issues The Coroner noted that the deceased's history of suicide attempts and self-harm was on record at the prison, and that no action was taken as a result. The deceased was also upset at the prospect of spending Christmas in prison after receiving an additional sentence in November. The findings also noted the effect of the two day lock down of the prison soon after he had cut his wrists, reportedly because high security prisoners had to be transferred to a facility one kilometre away. It was noted that the move into the adult prison was a contributing factor. The Coroner noted that the mogadon given to the deceased on the night of his death was not an appropriate or effective medication for his recognised severe depression. The findings contain criticism of the inadequate recording of information at all levels within the Correctional Centre, and inadequate awareness by staff of administrative requirements and management procedures. Recommendations The Coroner recommended that resources be made available so that adequate health services, particularly psychiatric services, be provided and maintained within institutions and additional qualified personnel and trained ancillary staff be recruited. Anomalies in the continuity of services and the paucity of thorough and contemporaneous records involving the treatment, counselling and welfare of prisoners should be addressed as a priority. There need to be adequate administrative directives and proper safeguards to ensure their fulfilment in respect of the following matters: 1. The proper and adequate recording of information regarding the welfare of prisoners, particularly younger prisoners with known self-injurious, irrational or disturbed behaviour; 2. The dissemination of information gathered to all levels of personnel within the centre; 3. The adequate exchange of information between staff members moving from different sections (or units) within the centre; 4. The attendance of all personnel at properly authenticated courses for the prevention of suicide, which should include methods of detection of prisoners considered to be potential suicide risks; 5. The attendance of all staff at approved courses in first aid and resuscitation techniques, which should include the requirement that a proficient standard be attained in the use and maintenance of relevant equipment employed; 6. All personnel be required to read and familiarise him/herself with the Recommendations of the Royal Commission into Aboriginal Deaths in Custody; 7. In the development of a plan of Management for younger offenders, designed to improve their well-being and for the better utilisation of their time, that input be sought from custodial officers (Aboriginal and non-Aboriginal) within the centre who have a proven genuine interest in schemes for the betterment of such offenders, and with a proven empathy with individual/s. That a structured plan be developed to ensure expeditious access to prisoners and their treatment in times of emergency. That the Police Service issue a directive to preserve clothing worn by a deceased person at the time of his/her death. Royal Commission Recommendations Breached R150 Health care should be of equivalent standard as general community. R151 Referral of Aboriginal prisoners/detainees for psychiatric care. R152a Review of health services provided to Aboriginal detainees with AMS and other bodies to consider standard of health services available. R152f Guidelines for exchange of information between medical and prison services. R152g(iv) Protocols for care and management of prisoners who have a history of self-harm. R152g(v) Protocols for care and management of prisoners who are angry and aggressive. R152g(vi) Protocols for the management of prisoners suffer mental illness. R152g(viii) Protocols for care and management of Aboriginal prisoners on medication. R153a Ongoing review of prison medical services. R154a Prison medical services staff to be trained in Aboriginal health, including history, culture and lifestyle; efforts to employ Aboriginal people in prison health services. R155 Training of prison officers to include Aboriginal health, information, risk assessment and appropriate emergency action to be taken. R158 The first response of police or prison officers to a person apparently dead should be to attempt resuscitation. R159 Availability of safe, effective resuscitation equipment and trained staff in all prisons and watch-houses. R161 Instructions to seek immediate medical care if doubts about prisoner's condition. R181 Segregation and isolation of Aboriginal prisoners to be avoided. Minimum standards for segregation including fresh air, lighting, daily exercise, adequate clothing and heating, adequate food, water and sanitation facilities and some access to visitors. Social Justice Commissioner Comment The death in an adult prison of a juvenile with mental health problems reveals the continuing need for comprehensive improvements in the standard of custodial health and safety. The Coroner made useful and important recommendations. The Royal Commission recommended that governments publish annual reports containing coronial recommendations and findings so that the coronial process can contribute to the development of safer custodial conditions. There is probably no jurisdiction with more avoidable deaths than Queensland. The evidence indicated that the visiting psychiatrist paid an insufficient degree of attention to the deceased's condition. The psychiatrist was semi-retired and failed to put a psychiatric report on file in three visits. No psychiatrist saw the deceased after he cut his wrists, as this psychiatrist was on leave and there was no replacement. Counsel for the family submitted the transcript of cross examination of the psychiatrist, which he claimed revealed a disgraceful standard of mental health care, to the Health Minister. Psychiatric services must be of a sufficient standard to detect prisoners at risk of suicide and provide appropriate care. It is in the interests of the community that prisoners with mental health problems receive adequate attention before they are released. It is inhumane not to provide adequate psychiatric services in the harsh environment of a prison. The Coroner also raised problems in the notification and counselling of the family. Additional Royal Commission Recommendations Breached
R7 Specific State/Territory Coroner for inquiries. R8 Development of specific rules for inquiries and inquests. R95 Where motor vehicle offences are a major factor in imprisonment, programs to be consultatively developed to reduce incidence. R165 Elimination/reduction of items with potential for self-harm. R167 Juvenile Detention Centres be reviewed to ensure compliance with custodial health and safety recommendations. R328 Resources to translate Standard Guidelines for Corrections in Australia into practice. R329 Legislation to to embody Standard Guidelines and prisoners rights, as in Victoria.
Coronial Inquiry Coroner Gary Casey Finding handed down on 28 May 1993 Finding The cause of death was (1) (a) acute cardial infarction due to, or as a consequence of, (b) coronary athrosclerosis; and (2) chronic alcoholism. Summing Up Circumstances of death At approximately 1:30pm on 25 May 1992 two police officers from Woollongabba Police Station attended at 22 O'Connell St, West End in response to a call from the occupants of one of the flats. The police assumed the deceased was intoxicated. The Coroner found she was incapable of walking unassisted or communicating spontaneously. She was conveyed to Brisbane City Watch-house with some of her personal belongings and charged with drunkenness. The Officer-in-Charge of the watch-house contacted Murri Watch, a community based care organisation, and told a worker that the deceased was at the watch-house and intoxicated. Approximately two and a half hours later, at around 3:55pm, police noticed she was unconscious. Resuscitation was attempted. The Queensland Ambulance Service was contacted and the deceased was conveyed to Royal Brisbane Hospital, arriving at about 4.30pm. Further attempts to revive her were unsuccessful. She was certified dead at 5:05pm. Issues The deceased had frequently been arrested for drunkenness and police assumed she was intoxicated. However, a post mortem conducted the following day revealed that there were no traces of alcohol in her body. It also revealed that the deceased had suffered the heart attack which ultimately killed her some 12-24 hours prior to her death, before police arrived at the watch-house. The questions that arise include: a. whether the inference that the deceased was intoxicated was reasonable; b. did the officers act unlawfully or improperly by removing the deceased from private premises to arrest her with public drunkenness under section 81 of the Liquor Act 1912? c. whether the Watch-house Keeper properly exercised his responsibility in accepting the charge of drunkenness against the deceased and detaining her in the watch-house pending anticipated arrangements for her release into the custody of Murri Watch; d. after the deceased was placed in cell number 11, were the actions of watch-house staff and prevailing watch-house conditions, procedures and staff training of a sufficient standard to properly address the situation of her incarceration? The areas of concern were prisoner inspections; first aid training, including the use of oxy viva equipment; and the information given to ambulance officers; e. was the investigation of a sufficient standard to provide a thorough and impartial evidentiary base for the purposes of: (i) a coronial inquest into the case and circumstances of death; and (ii) establishing whether any inaction or failure by any police officer to provide due care or supervision, other than in a criminal sense, caused or contributed to the death. Recommendations The Coroner made the following recommendations: 1. While it remains possible for a person to be detained in police custody for an offence of being drunk in a public place, the inherent difficulties confronting police officers of distinguishing between drunkenness and other non-related medical conditions to determine whether a medical risk exists are exemplified by the circumstances associated with the instant death. It is impracticable for the responsibility for making medical assessments of persons in custody to be entrusted to unqualified non-medically trained personnel. Adequate administrative initiatives be implemented as a matter of priority to remove what I perceive to be an unfair and unrealistic onus on Police Service personnel, particularly those employed in the role of Watch-house Keeper. 2. The proposed Queensland Police Service Custody Manual which makes provision for implementation of the various responses to recommendations 127, 131, 132, 133, 135, 136, 138, 145, 159, 160, 161 and 223(b) of the Royal Commission into Aboriginal Deaths in Custody be adopted without avoidable delay. The suggested recommendations are complementary to other guidelines currently followed by police. 3. In so far as giving effect to the principles of recommendations 135 and 136, provisions be made to alert police personnel to those detainees, who although apparently conscious, have difficulty for no obvious acceptable cause, in articulating his or her thoughts or verbal responses. Royal Commission Recommendations Breached R127a Regular medical presence in watch-houses in capital cities and other major centres R127f(i) Rules for care and management of Aboriginal persons who are intoxicated. R132 Information exchange at change of shifts; written checklist for handover at change of shift; need for proper form for handover at change of shift. R133 Training of police officers to recognise those in distress or a risk; content of this training; advice and assistance of AHS and ALS in design and delivery of such training. R135 People unconscious or not easily roused to be taken to a medical service, not a watch-house. R136 People found unconscious or not easily roused to have immediate medical care. R138 Police instructions to require recording of information relevant to well-being of detainees. R145 Aboriginal cell visitor schemes or similar in police watch-houses; Aboriginal community management (with appropriate funding); scheme not to reduce duty of care owed to detainees. 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. R161 Instructions to seek immediate medical care if doubts arise about a prisoner's condition. R223b Negotiated protocols for protective custody by virtue of intoxication. Social Justice Commissioner Comment The coronial inquest was totally inadequate as the only public record of the investigation into the circumstances of the death. It does not serve the public interest in dispelling suspicions about the death. The conduct of the police was not scrutinised by the Coroner. The twelve police officers invoked the privilege against self-incrimination and declined to give evidence to the Inquest on advice from counsel. They answered questions after the inquest when directed by a senior officer to do so. A journalist posed the question at the time 'If an elderly non-Aboriginal woman was seen in a distressed state, would it be assumed that she was drunk and thrown into prison?' 8 The case was referred to the Queensland Criminal Justice Commission for inquiry into the police conduct. Unfortunately, these investigations are not public. The basic findings of that inquiry are set out below. The case obviously raises the inappropriateness of the criminal penalty for public drunkenness. The Royal Commission recommended police monitoring to ensure that intoxicated persons are not inappropriately held in protective custody despite the decriminalisation of public drunkenness (R85). This case illustrates the importance of monitoring in jurisdictions where public drunkenness is still a criminal offence. The investigation by the Criminal Justice Commission was even-handed and complete, in contrast with the incomplete nature of the investigation by the Coroner, particularly the finding that there was no police impropriety despite hearing no evidence from police officers involved. Points not included in the Criminal Justice Commission investigation appear in italics in the summary below in italics. Criminal Justice Commission The Inference that the Deceased was Intoxicated The Criminal Justice Commission investigation found that there was no basis for charges to be laid against the arresting officers, although investigators rejected their claim of noticeable odours of alcohol. The inference of intoxication was reasonable given the slow and slurred deliberate response to questioning, the inability to stand, the difficulty in focussing, the absence of signs of discomfort, and the fact that the residents of the flat were of the same opinion. The Appropriateness of the Arrest The investigation found that arrest was preferable and sensitive as the deceased was incapable of looking after herself. The investigator doubted that the officer had checked to see if there were other Aboriginal people in Musgrave Park who could have taken care of the deceased. General Instruction 10.12 of the Custody Manual was noted. It requires that persons being removed from premises be left absolutely free as soon as the street or public road is reached if they are not engaged in criminal conduct. The Duties and Behaviour of the Watch-house Keeper The behaviour of the Watch-house Keeper was scrutinised. The duty was to determine the propriety of the charge, and the condition of the deceased. He was found to have formed a preliminary view that the deceased was unconscious, and not appropriate for detention. The evidence of conscio | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Site navigation
Change font size: 
