Report by the nsw state Coroner into deaths in custody/police operation


Examination of the Matters in Issue



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Examination of the Matters in Issue

It has been clearly demonstrated, not only in Counsel assisting’s opening address, but also during the course of the evidence that a number of issues have been identified.


By way of summary those issues could best be described as the following:


  • 2 August – The 000 call by IP and its categorisation as a ‘Concern for welfare’

  • 2 August – The Police response and actions following the events at another address.

  • 4 August – Police action in seeking a Domestic Violence order

  • 28 August – Complaint by IP of a breach of the Domestic Violence Order and the Police response

  • 15 September – Complaint by IP of a breach of a Domestic Violence Order, Police response and subsequent actions.

  • DOCs involvement and issues surrounding prioritisation and allocation of a mandatory notification.

A further issues in regard to the provisions of Section 562H(2A) of the Crimes Act 1900, as amended was identified during the course of this Inquest, and while perhaps not having direct implication in the events associated with this Inquest, it is a matter of significant importance that will require consideration and possible formal recommendations. (This issue deals with the inability, if warranted, for Constable B to seek a telephone Interim Order by virtue of the decision in Woods v Evans & Anor. Justice Kirby, NSWSC 27 April 2005).


The Deputy State Coroner now dealt with those identified issues and in doing so took into account the written and oral submissions and the sworn testimony and views expressed by the P family.

The Triple 000 Call on 2 August 2003

There would seem to be little doubt and overall agreement that the classification of the 000 call by the Radio Operator as a concern for welfare was inappropriate. It is clear from the transcript that IP told the operator that, and quoting from that transcript, “he pulled a knife out and said he was going to kill himself, I managed to get, sort of calm it down and get the knife off him. I don’t know whether he’s really meaning it or not but the kids were both there and it was in front of them, so I managed to calm it down and got myself and my son home but my daughter’s still in the flat.” Operator to IP, “he’s only threatened self harm has he, he didn’t assault you or anything like that”…answer… “No, no last week he said he was going to come and kill me and kill himself”. Clearly the radio message from the 000 Operator to the Police should have clearly indicated that the situation was a Domestic Violence situation. The report prepared by Ms H has also identified the error and she has reported that a revision of training for VKG Operators in terms of Domestic Violence issues is now provided. On the assumption that this training has been implemented and will be on-going the Deputy State Coroner saw no need to make formal recommendations. It is, however, important that in the training it must be stressed that the identification of domestic violence issues, is not only imperative in terms of the nature of the response, but also in terms of providing Police who are called out with the opportunity to do background checks in terms of Officer safety.



2 August 2003 and Police Response

There is absolutely no doubt that the response by Officers V and L to the ‘Concern for Welfare’ notification was prompt and that from the information provided by IP to those officers the priority was focused on securing the safe release of MK. There is also no doubt that the concerns that the Police had for the welfare of PK and their actions in seeking information regarding assistance and counseling was appropriate and commendable, even though the request for assistance was instigated by PK.


The question that remains unanswered and on which there remain different views, is whether the Officers should have identified the circumstances of the events at the flat as a domestic violence situation. It is conceded that the Officers were entitled to the view that they were dealing with a concern for welfare, however it would also have been obvious to the officers that the concern for welfare involved a family and 2 children. It would not have been unreasonable for the officers to probe further in obtaining background information on the dynamics of the family. I note from reading Constable V’s statement that no reference appears anywhere in regard to any enquiry of IP, he does however, say, quote, “she did not disclose any other information that may have constituted a criminal offence.” It appears from the tenor of Constable V’s statement that he certainly asked all the relevant questions in regard to the issue of concern for welfare, however it would not have been unreasonable to enquire of IP as to whether threats had been made to her. We are all aware from the evidence that IP did not disclose to Constable V that she had received a threatening letter. There is no doubt that the Police acted appropriately on this night and to some extent were assured by IP that her concerns were mainly for PK. The unfortunate circumstances in which the radio message did not communicate a reported threat of harm by PK to IP resulted in that information not being followed up.
If any lesson is to be learnt from the events of 2 August it is perhaps the need for officers to look outside the square when dealing with what may be a concern for welfare in a domestic situation. Notwithstanding that PK had indicated that he had no intention of harming himself, he did seek assistance and counseling and it would not have been unreasonable for the officers to seek further background information on the relationship and its breakdown in order to make informed decisions and appropriate follow up if necessary.

4 August 2003, Constable B and the AVO Application

The Deputy State Coroner closely examined the events of 4 August and the role Constable B played. He agreed with one of the parties that her approach was both caring, sympathetic and professional. It is also evident that Constable B accessed the COPS system and even spoke to Constable V concerning the events of 2 August 2003. Having regard to the information provided by IP it was appropriate and necessary to seek an apprehended violence order and Constable B took action in that regard.


An issue has arisen as to whether a telephone interim order should have been applied on 4 August. Apart from the possible legal technicality (which will be dealt with later) the Deputy State Coroner was of the view that the circumstances outlined by IP to Constable B did not constitute sufficient immediate concerns that would warrant a telephone interim order. Similarly, it was open for Constable B to place the complaint before a presiding Magistrate at Windsor at 10am the following morning and to allow the Magistrate to either take sworn testimony from IP or question her in regard to whether an Interim order should be made. A decision was made by Constable B to lodge the complaint through the Court Registry and a return date for 27 August 2003 was arranged.
Having regard to the information that was provided to Constable B her actions in listing the complaint returnable on 27 August 2003 was not unreasonable and it is perhaps only with the benefit of hindsight that we now know that PK’s mental and emotional state was deteriorating. The only issue that perhaps is worthy of comment is the desirability when seeking a restraining order to closely look at the history of the relationship and its evident and escalating deterioration in the preceding days and weeks. In cases where there has been a recent separation, children involved, threats to kill the spouse and threats to self harm with a knife, it may be desirable to seek either an earlier return date with expedited service or consider seeking an Interim order. The reality is that IP and her children had no protection between 5 August and the return date, 27 August 2003, a period of 22 days.



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