Report by the nsw state Coroner into deaths in custody/police operation
To the Minister of Police and Commissioner of Police
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- 1754/03 Inquest into the death of VH on 12 October 2003. Finding given 18 March 2005 at Bourke by Magistrate Jacqueline Milledge, Senior Deputy State Coroner.
- Formal Finding That VH died on 12 October 2003 at Brewarrina. Inquested terminated, and referred to the Director of Public Prosecutions.
- Formal Finding: That RB died on 9 October 2003 at Mt Mackenzie via Tenterfield of a shotgun wound to the head, inflicted then and there with the intention of taking his own life.
- Formal Finding. That JN died in custody on or about 11 th November 2003 at Area 3, Long Bay Correctional Centre, Malabar of a natural cause, to with ischaemic heart disease.
- 147/04 Inquest into the death of MA on 8 February 2004 Finding given 24 March 2005 at Tumut by Magistrate Carl Milovanovich, Deputy State Coroner
- Formal Finding: I find that MA died on 8 th February, 2004 at Tumut Hospital Tumut in the State of New South Wales from a Chest Injury following impact with a motor vehicle.
To the Minister of Police and Commissioner of Police
1754/03 Inquest into the death of VH on 12 October 2003. Finding given 18 March 2005 at Bourke by Magistrate Jacqueline Milledge, Senior Deputy State Coroner. VH, an aboriginal woman, was a passenger in a vehicle being pursued by police. The driver had failed to stop for a random breath test in Brewarrina and was pursued by a general duties vehicle and a highway patrol officer. The pursuit continued onto a dirt road where the driver lost control, rolling the vehicle several times. VH was thrown through the back window and killed. After taking evidence from all witnesses the inquest was terminated pursuant to Section 19 of the Coroner’s Act and referred to the Director of Public Prosecutions. Formal Finding That VH died on 12 October 2003 at Brewarrina. Inquested terminated, and referred to the Director of Public Prosecutions. 1833/03 Inquest into the death of RB on 9 October 2003. Finding given 26 July 2005 at Armidale by Magistrate John Abernethy, State Coroner. Circumstances of Death: This matter was assessed as a death during police operation within the meaning of Section 13A, Coroners Act 1980, on the basis that the deceased was probably alive when a police operation to locate him began. Police were notified that the deceased had indicated to a relative and friend that he was at Mt Mackenzie and intended to take his own life. The friend notified police who immediately attended Mt Mackenzie and located the deceased who had died of a self-inflicted shotgun wound to the head. The deceased had been suffering from depression and had been receiving medication for his condition. On 9 October 2003 the deceased had been in a depressed mood despite a recent alteration to his medication regime. He left for work at about 8.30am on 9 October. At about 10am his wife telephoned the deceased to check on his welfare. He stated that he was going away, apologised to her and told her that he loved her. Soon after the wife telephoned again but could not contact her husband. At about 10.30am the deceased telephoned work to speak to his employer. He spoke to the wife of the employer. He told her that he felt the medication was not working and that he was going to shoot himself. He told her to tell police to go to Mt Mackenzie. Another employee informed police who immediately went to the Mt Mackenzie area. After a short search the deceased’s vehicle was found. He was then located deceased. The deceased had made his intention clear and the State Coroner was satisfied that he had taken his own life. The NSW State Coroner was satisfied that the police operation to locate the deceased was conducted appropriately. He could see no other issues which might warrant comment, other than to say that this was a “police operation death” in the most technical sense of the term. Formal Finding: That RB died on 9 October 2003 at Mt Mackenzie via Tenterfield of a shotgun wound to the head, inflicted then and there with the intention of taking his own life. 1943/03 Inquest into the death of JN on 11 November 2003. Finding given 25 January 2005 at Glebe Coroner’s Court by Magistrate John Abernethy, State Coroner. Circumstances of Death. This prisoner died in his cell at Long Bay Correctional centre on the night of 10th – 11th November 2003. He was found deceased at “let-go” on the morning of 11th November. All death in custody protocols were followed. A post mortem examination was conducted by a forensic pathologist and he was found to have died of ischaemic heart disease. A social worker raised the issue of the adequacy of the prisoner’s medical treatment, as did his next of kin. It was agreed that that was the only issue at inquest. Dr. M was called. Dr. M as head of the (then) Corrections Health Service gave frank evidence to the State Coroner. He detailed the course of treatment over the last two years of the prisoner’s life. During this time the prisoner underwent specialist testing and as a result of this received an angioplasty (stent). The prisoner suffered an apparent myocardial infarction on the night of 21st July 2002, whilst waiting for assessment. A Registered Nurse was able to ease his pain with appropriate medication and as a result applied existing protocols and did not immediately call an ambulance. The pain returned the next morning and he was immediately transferred to Prince of Wales Hospital for examination, angiogram and angioplasty. It is fair to say that the prisoner was bitter that he was not hospitalised at the time of first pain. Despite regular medical consultations up until the time of his death, the prisoner remained critical of the treatment he had received and just prior to his death indicated that he wanted no further treatment unless for a life threatening illness. The death. The prisoner’s cell call alarm was not activated and on investigation was found to be operating efficiently. The prisoner was found on the floor of his cell and had suffered minor injuries. The State Coroner found it to be probable that he collapsed and died before he could activate his cell call alarm. Conclusion. The NSW State Coroner was satisfied that the care and treatment of the prisoner was at all relevant times, adequate. The judgment of the nurse as to immediate hospitalisation was a hard one to make and in essence the nurse applied the correct protocol. The State Coroner listened to the evidence of Dr. M and as a result made a recommendation in relation to approaching Australian Health Department in relation to prisoner access to Medicare. Formal Finding. That JN died in custody on or about 11th November 2003 at Area 3, Long Bay Correctional Centre, Malabar of a natural cause, to with ischaemic heart disease. Recommendation. That the New South Wales Minister for Health considers approaching the Federal Minister for Health in order to attempt to obtain “Medicare access” for prisoners in NSW Prisons and Juvenile Detention Centres. 147/04 Inquest into the death of MA on 8 February 2004 Finding given 24 March 2005 at Tumut by Magistrate Carl Milovanovich, Deputy State Coroner The deceased was a 71 year old male who had lived and worked in the Tumut area for most of his life. Evidence was given that whilst in relatively good health, he was legally blind in his right eye and suffered from a severe hearing impairment, which required him to wear hearing aids in both ears. At 11.19am on Sunday 8th February, 2004 the deceased was walking along the footpath of Wynyard Street, Tumut which runs past the police station. At the same time, a police vehicle Reg No: YAS 946 was reversing from the driveway of the police station to respond to a domestic violence incident. The officer driving the vehicle felt a bump, and on inspection, it was found that the deceased was then under the police vehicle. He was attended to by a nurse, ambulance officers and paramedics, before being taken to Tumut Hospital where he passed away at 3.05pm. There is no doubt in the Coroners mind that this was a tragic accident, but it was avoidable. All police are required to drive in accordance with the police safe driving policy and if implemented on this occasion, this incident would have been avoided. Evidence was given of an informal practice to drive vehicles into the police driveway and then turn them around. There did not however appear to be any formal directive or policy in regard to this practice. There was also evidence to suggest that shrubbery on the eastern side of the driveway severely restricted vision of a reversing vehicle. It was submitted that the current policy still allows a discretion in regard to the escort alighting from a vehicle and providing guidance where vision is restricted due to the construction of the vehicle. The Coroner does not believe that the policy is an any way ambiguous in that it clearly states if vision is restricted, that guidance from an escort is required. The Coroner was informed that it was intended to reconfigure the driveway at Tumut police station to make it a ‘U’ shape which would result in all vehicles exiting the driveway in a forward manner. No formal recommendation will be made in relation to this issue but the Coroner would strongly urge that the proposal be implemented as soon as possible. Formal Finding: I find that MA died on 8th February, 2004 at Tumut Hospital Tumut in the State of New South Wales from a Chest Injury following impact with a motor vehicle. 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