Coronial Inquiry Coroner Ian Matherson
Finding handed down on 4 November 1992
The deceased died by hanging himself.
Circumstances of death
The deceased was serving a life sentence for murder, having been convicted on 26 April 1978. In April 1991 he was granted permission to attend the University of Tasmania to undertake a bridging course. The deceased signed an agreement which regulated his attendance at the course. He breached the agreement on 15 August 1991 when he left his authorised custodian and consumed alcohol. He was subsequently informed he would be returned to maximum security with a review of his current arrangements and classification.
The deceased responded by threatening to kill himself. He was transferred to the prison hospital. He received a Category A Special Risk Classification. He was subsequently assessed by a prison psychologist as only being a suicide risk if he was returned to the maximum security prison. He was downgraded to Category B where he was allowed a cigarette and a book. On Monday 19 April he was downgraded to Category C. This allowed him to mix with other inmates. He met with the psychologist and again expressed his fear of maximum security prison. It was decided he should remain at the prison hospital until another form of punishment was considered.
The deceased was aware of this decision and showed optimism in achieving a positive result. However, friends and visitors stated that he became more depressed and lost his will to continue. The deceased was observed every thirty minutes in accordance with Category C classification. On the 26 August 1991 he obtained a piece of cloth and hung himself between 3:00am and 3.30am. He was discovered at 3.30am but no resuscitation was attempted.
The Aboriginal Legal Service submitted that the prison authorities failed to properly exercise their duty of care in a number of respects: that the risk of suicide was increased by the delay in determining a suitable punishment; the lack of multi-prisoner cells in the prison hospital; and the unsafe nature of the cells. They also argued that nurses should have attempted resuscitation.
The Coroner found that the standard of care was appropriate. He found that classification as category C would have been inappropriate if the prison authorities had known of conversations between the deceased and a custodian and friend. He accepted the evidence of the nurse that resuscitation would have been futile but noted the absence of a defibulator.
The Coroner did not address the issues of either the delay in punishment or the lack of multi-prisoner cells. However, he commented on the insufficiency of psychiatric care provided in the prison hospital.
That psychiatric facilities be upgraded, including the provision of sufficient, qualified staff.
Royal Commission Recommendations Breached
R 150 Health care should be of equivalent standard as general community.
R 151 Referral of Aboriginal prisoners/detainees for psychiatric care.
R152a Standard of general and mental health care available to Aboriginal prisoners.
R 152d Facilities for behaviourally disturbed.
R152f Guidelines for exchange of information between medical and prison services.
R159 All prisons and watch-houses should have resuscitation equipment.
Social Justice Commissioner
The Coroner should have addressed the issue of the delay in punishment and the necessity for punishment in this case. It was a contributing factor in the deceased's death. A punishment may not have been necessary considering that: (i) the deceased's custodian at university was partly responsible for the breach of the agreement; and (ii) it was an inaugural exercise. The Royal Commission was concerned with punishment within prisons, particularly its secrecy. Recommendation 180 states that prisoners charged with offences should be tried in public courts. The Coroner should have addressed the issue as it relates to both the prisoner's health and the administration of justice.
The deceased was also fearful of threats made in maximum security. This case, like the profile 72NSW indicates the problem of prisoners seeking protection in prison hospitals by threatening, or undertaking, self-harming activity.
It is also unfortunate that the Coroner did not address the issue of multi-prisoner cells despite the submission of the Aboriginal Legal Service.
Additional Royal Commission Recommendations Breached
R12 Legal requirement for Coroner to consider how the person was treated before death.
R13 Coroner to recommend ways to prevent further deaths.
R152g(iv) Protocols for care and management of Aboriginal prisoners at risk of self-harm.
Coronial Inquiry Coroner Peter Wilson
Finding handed down on 11 March 1994
The deceased died on the 12 August 1993 from exsanguinations secondary to torn iliac vessels from a gunshot wound. The wound was sustained on 11 August 1993 when the deceased confronted a constable outside the Top Shop at Waverly with a pistol (later found to be a replica) and the constable, acting in self-defence, discharged his firearm at the deceased's stomach.
Circumstances of death
Police were called to Waverly after receiving a report that a male, armed with a pistol, was trying to break into a shop. Two constables arrived at the scene simultaneously. Constable W was approached by the deceased. According to the Constable the deceased walked to within 1.5 metres of him and pointed the pistol at his head. The Constable backed away with his hands raised and the deceased followed. The Constable attempted to persuade the deceased to drop the gun.
Constable V called to out to the deceased. As the deceased turned Constable W drew his revolver. Constable W continued his attempts to persuade the deceased to drop his gun. The deceased stepped forward and Constable W shot him in the stomach. The deceased was taken to Launceston General Hospital where he died the following day.
The Coroner found nothing to criticise in the behaviour of the Officers and held that Constable W had acted justifiably in self-defence. He also found the training of police in the use of firearms to be adequate and appropriate.
The Coroner considered various criticisms of the post-death investigation, in particular police investigating police. He was satisfied that the investigation was objective and pointed out that investigating police came under the jurisdiction of the Coroner. However, he was not satisfied with the investigation by the Police Internal Investigation Unit: police not connected to the Unit conducting interviews of the constables involved; interviews delayed for a significant period of time, unlike civilian interviews; and leading questions being used. The Coroner also considered it bad judgment on the part of senior police to offer the justification of self-defence before the Unit had finished its enquiries.
The Coroner was of the view that the inquest was not an appropriate vehicle for the advancement of issues concerning Aboriginal deaths in custody. He stated that the deceased was not technically in custody since he, and not the police, were in control of the situation.
The Coroner expressed concern that replicas could come into the hands of immature or irresponsible people but made no recommendations on the matter.
Royal Commission Recommendations Breached Nil.
Social Justice Commissioner
The death was clearly a death in custody since the death occurred 'in the process of the police � attempting to detain that person' (Recommendation 6c). The Coroner's comment that this was not a death in custody was in disregard of the address by Counsel for the family, who stressed the importance of the findings and recommendations of the Royal Commission into Aboriginal Deaths in Custody as they related to this case.
There was evidence presented during the inquest that the deceased was frequently taunted for his speech impediment. This generally resulted in the deceased becoming aggressive. There was unchallenged evidence that police officers had previously provoked the deceased regarding his impediment, although not the police officers involved in the stand-off situation. Counsel for family submitted that this previous provocation and the deceased's intoxicated state may have led to his to aggresive attitude towards the Police Officer. The Coroner did not address the causes of the deceased's behaviour.
The deceased became a heavy drinker on leaving school. He was initially charged with a significant number of stealing offences and was made a ward of the State. However, in the two years before his death the deceased was more frequently charged for drunk and disorderly conduct. Public drunkeness is still a criminal offence in Tasmania despite Royal Commission recommendation 79.
There was significant debate on the availability of replica pistols after the death of the deceased. The Coroner did not consider the appropriateness of their availability.
The Coroner also failed to address submissions from Counsel assisting him as to police training and protocols regarding firearms. Counsel stated:
It is perhaps a reflection of our society that police officers are now armed as a general rule in this State. I suggest it is not something that the public is comfortable about and any use of the same is a matter of public concern. Reference in these proceedings was made to the Standing Orders and the Commissioner of Police directions as to the use of lethal force. There appears to be some different perception by the Police Officers who gave evidence as to those documents and there is even some possible inconsistencies between the two... I would suggest, given the illustration of those difficulties with the understanding of Police Officers that maybe the Police Department ought to examine the Law and it's internal doctrine as to the use of firearms and to ensure that a clear and unambiguous direction can be given to Police Officers ..... There seems some doubt as to the instruction to Police in stand-off situations in that they appear to be relying on their own common sense.... It may be a matter also that ought be considered [is that] Police Officers .... have at least some outline of how to defuse that sort of situation.
Additional Royal Commission Recommendations Breached
R 6c Definition of 'deaths in custody' to include deaths occurring in the process of police or prison officers attempting to detain that person.
R 13 Coroner to recommend ways to prevent further deaths.
R79 Abolition of offence of public drunkenness.
A Report prepared by the
Office of the Aboriginal and Torres Strait Islander Social Justice Commissioner
Aboriginal and Torres Strait Islander Commission