Coronial Inquest Recommendations

There has been a great deal of discussion within the community about issues relating to alcohol use and abuse including underage drinking and the possible decriminalisation of public drunkenness. I intend to submit my Findings in this inquest to the Attorney-General for his attention with the recommendation that it be referred to the Law Reform Commission for consideration as a case study in what can go wrong in the existing legislative framework.

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

Paragraph 7 of the guidelines concerning community Justice Panels should be amended so that the words "identifies themselves" are substituted by the words "claims to be". The guidelines should also designate the specific officer who shall contact the Missing Persons Bureau and the Community Justice Panel when an Aboriginal person is detained.

Consideration should be given to the up-dating of printed material designated to accompany lectures to recruits. Consideration should be given to other ways of exposing recruits to information about Aboriginal culture and communities, within the constraints of time imposed by the pressures of a 20 week course. Other courses should be available at a later stage in a police member's career offering further education.

Consideration should be given to ways of improving lines of communication within the Police Force. It is apparent that a substantial amount of information and understanding at the level of the higher ranks is not reaching recruits and sub-officers.

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

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

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

That consideration be given to establishing within the Police Force, a specialist professional unit, appropriately trained, and equipped so that its members are in a position to take over from operational members during high risk crisis situations. The existing CAT teams are not in a position to meet this need, nor are the police negotiations from the Protective Services Group.

That members attached to the L.E.A.P. Management Project remain vigilant in ensuring that as far as possible, the computer system maintains complete, accurate and up to date entries.

That police members, directly involved in a death resulting from contact between police and the public, have their interview pursuant to paragraph 3.4 of the Standard Operating Procedures, either video or tape recorded. Just as the position held by a Police Officer, carries with it rights and privileges, it also carries the obligation of accountability. In being called to account, the officer and the community are entitled to the most accurate record of explanation.

That when preparing the inquest brief involving a death resulting from contact between police and the public, investigators ensure appropriate background material concerning the member’s police service is included in the brief.

That the responsible officer from the Police Internal Investigation Department, be vigilant in actively overseeing the investigation into a death resulting from contact between police and the public.

I adopt the recommendation made by the State Coroner in previous inquest involving a death resulting from contact between police and the public, (the most recent being Skews and Crome 1304 and 1305/94) of the need for ‘Critical Incident Review’ of each incident. This is essential in order to assist the Police Force to identify potential areas for improvement and for the coronial investigation process.

That Victoria Police considers using the facts of this case as a teaching resource to assist in developing an understanding in all members being inducted into Victoria Police, the expectations placed upon them for responsible policing.

That Victoria Police review what is being taught to recruits and disseminated throughout Victoria Police as to obligations to members of the public being transported by Victoria police when not under arrest or in custody.

That Victoria Police ensure that great caution is exercised in the immediate wake of any death and that every attempt is made to ensure that only accurate information is communicated to any other person.

That Victoria Police consider requesting members directly involved in a death in police custody, care or control to participate in an electronically recorded interview as soon as practicable after the death.

Both the OCSR and Justice Health should ensure the smooth implementation of the proposals contained in their submissions in accordance with best practice principles and including: Justice Health proposals to: amend the Notifiable Incident/Event Report template and guidelines including review of medical alert rating, risk rating, medical status and outcome; develop a template palliative care plan to be used with palliative care prisoners; and review the process to be followed for the purpose of a plea for mercy, so that a formal protocol is provided to contracted health service providers.

The Office of Correctional Services Review proposal to amend the terms of reference and content of their reports and identify any deficiencies to better inform.

I recommend that G4S commission independent research into the safest efficient way to dispense medication to prisoners in the Borrowdale Unit of Port Phillip Prison incorporating consideration of:

I recommend that the offence of public drunkenness be decriminalised and that section 13 of the Summary Offences Act 1966 be repealed.

G4S reiterate to staff undertaking the 'lock-down' of the Borrowdale Unit that a verbal, spoken response must be obtained from each and every prisoner. If such a response is not forthcoming from an enquiry made through the 'trap', the cell door is to be opened and a verbal response their obtained from the prisoner.

I recommend that the Victoria Police Manual Rules and G uidelines be amended to include a falls risk assessment as part of the detainee risk assessment for each person in custody who appears to be affected by alcohol or drugs or illness.

I recommend that there be a review of training and education within Victoria Police regarding the findings and recommendations of the Royal Commission into Aboriginal Deaths in Custody to ensure knowledge and appropriate compliance.

I recommend that there be a review of training and education within Victoria Police regarding the findings and recommendations of the Royal Commission into Aboriginal Deaths in Custody to ensure knowledge and appropriate compliance.

I recommend training be implemented within Victoria Police regarding the medical risks of individuals affected by alcohol.

I recommend Victoria Police request the Victorian Equal Opportunity and Human Rights Commission to conduct a section 41(c) review of the compatibility of its training materials with the human rights set out in the Charter.

I recommend V/ Line review training materials to include input from the Aboriginal and Torres Strait community about unconscious bias and to provide training to staff as to how to reduce the impact of unconscious bias in decision making.

I recommend V/Line request the Victorian E qual Opportunity and Human Rights Commission to conduct a section 41(c) review of the compatibility of its training materials with the human rights set out in the Charter.

That the Pursuits Policy mandate that the following requirement must be satisfied before commencing a pursuit:

Training must ensure there is no scope for interpretation … [of Recommendation 1]. That the [pursuit] policy means what it says.

[Pursuit] Policy must require neither UDD [(Urgent Duty Driving)] nor pursuit be conducted unless police are always aware of their speeds.

In every pursuit, irrespective of outcome, policy require members to record for review, the serious risk which existed before the decision to intercept, that is before police involvement.

That the Victorian government consider funding allocations sufficient to facilitate achievement of the recommendations that follow.

That the Victorian Government in consultation with Victoria Police, the Department of Justice and Community Safety, the Department of Health and peak Aboriginal and/or Torres Strait Islander organisations urgently develop a review and implementation strategy for the State’s implementation of the 339 recommendations of the 1991 Final Report of the Royal Commission into Aboriginal Deaths in Custody.

Urgent review of the Bail Act with a view to repeal of any provision having a disproportionate adverse effect on Aboriginal and/or Torres Strait Islander people.

Urgent legislative amendment of the Bail Act including that:

Legislative amendment to section 464FA of the Crimes Act 1958 (Vic) (Crimes Act) to require an investigating official to inform an Aboriginal and/or Torres Strait Islander person in custody not only that the Victorian Aboriginal Legal Service (VALS) has been notified that the person is in custody but also that:

Legislative amendment to sections 464A(3) and 464C of the Crimes Act, respectively, to require, in accordance with the principles known as the Anunga Principles, an investigating official to explain to an Aboriginal and/or Torres Strait Islander person in custody in simple terms:

That the Chief Commissioner of Victoria Police amend any Victoria Police Manual (VPM) policies and guidelines to

8.1: That the Chief Commissioner of Police review and if necessary update its training to all members to highlight the requirement that police members, as a Public Authority under the Charter, are required to act in accordance with the Charter when making decisions in the course of their duties. The training should provide members with knowledge and skills enabling members to use the Charter in the real-life decisions they make in the performance of their duties. Its aim should be to embed the Charter in police practice not merely raise members' awareness that the Charter is 'relevant' to Victoria Police as a public authority.

That the Victoria Police partners with appropriate Aboriginal Community Controlled Organisations to develop and implement a strategy for ongoing cultural awareness training, monitoring and performance review for all members.

G4S [Custodial Services] and SVCHS [(St Vincent's Custodial Health Services)] staff receive training to assist them in recognising and managing drug affected prisoners, including those who may be experiencing ABD [(Acute Behavioural Disurbance)] and drug toxicity, and its effect on their decision making capacity.

SVCHS [(St Vincent's Custodial Health Services)] receive training about the practical application of the Acute Poisoning Management Guideline.

SVCHS [(St Vincent's Custodial Health Services)] staff receive training to reinforce their authority and responsibility to advocate for the treatment of prisoners in their care and to escalate where appropriate.

G4S [Custodial Services] TOG [(Tactic's and Operations Group)] staff receive training about the importance of consulting with medical staff prior to cancellation of a medical escort.

SVHM ED staff receive training about the limitations of providing medical treatment in prison; the benefit of communication of a prisoner’s treatment plan with escorting correctional staff; and the importance of prompt preparation of a discharge summary including the treatment plan.

G4S staff receive training about the circumstances in which they can exercise individual discretion to allow medical staff to enter a cell to provide a prisoner with medical treatment.

Corrections Victoria develop and implement a training program, to be undertaken by correctional staff and medical staff together:

I recommend that the current volunteer model for the Aboriginal Community Justice Panel be reviewed as to its effectiveness in providing protection for Aboriginal people in custody and that this review include a clarification of the services offered by the Aboriginal Community Justice Panel with both Victoria Police and the Victorian Aboriginal Legal Service.

That the Chief Commissioner of Police urgently correct any misunderstanding suggestive of an 'informal policy' that:

That the Chief Commissioner of Victoria Police require police BDMs to undertake periodic training to address the interpretation and application of section 3A of the Bail Act.

That the Chief Commissioner of Police collect and retain statistics that identify:

That the Magistrates Court of Victoria ensure that the Court Integrated Services Program (CISP) is staffed whenever the court is open, including throughout Bail and Remand Court sessions.

"That the Magistrates’ Court of Victoria employ sufficient Aboriginal or Torres Strait Islander staff in roles (however described) within the court to provide assistance to and, where necessary, advocacy for, Aboriginal and Torres Strait Islander court users including people remanded in custody, and develop and implement:

That the Magistrates’ Court of Victoria collect and retain statistics that identify:

That the Victorian Legal Admissions Board consider requiring that Practical Legal Training course providers deliver compulsory Aboriginal and Torres Strait Islander cultural awareness training as part of the curriculum.

That the Legal Services Board and Commissioner and the Victorian Bar consider including Aboriginal and/or Torres Strait Islander cultural awareness training as a mandatory requirement of continuing professional development for practising legal practitioners.

That the Department of Health and the Department of Justice and Community Safety:

That Justice Health:

That Justice Health review and, if necessary, revise the Justice Health Quality Framework.

That the Victorian Government establish a subacute unit at the Medical/Health Centre at Dame Phyllis Frost Centre available to all prisoners who require it, and that includes oversight by a specialist who has completed Advanced Training in Addiction Medicine.

As an interim measure, until a subacute unit on site at Dame Phyllis Frost Centre is operational, I recommend that an agreement or Memorandum of Understanding be agreed as a matter of urgency between Corrections Victoria, Justice Health and Correct Care Australasia and/or the Health Service Provider at the Dame Phyllis Frost Centre and the most appropriate proximate public hospital for the provision of equivalent community health services not presently provided at the Medical/Health Centre.

That the Victorian Government establish at the Medical/Health Centre at the Dame Phyllis Frost Centre Point-of-Care testing in accordance with requirements that are equivalent to the Royal Australian College of General Practitioners Standards for Point-of-Care testing.

That the Department of Justice and Community Safety and/or Justice Health, in partnership with the Victorian Aboriginal Community Controlled Health Organisation (VACCHO), take concrete steps to build the capacity of VACCHO to provide in-reach health services in prisons.

I recommend that Justice Health and Correct Care Australasia and/or the Health Service Provider at Dame Phyllis Frost Centre ensure that all Aboriginal and/or Torres Strait Islander prisoners have the option during the reception medical assessment of consulting with an Aboriginal Health Practitioner or Aboriginal Health Worker, either in person or by telehealth, within 48 hours. The prisoner’s response to this offer should be documented. An alternative to this recommendation will be implemented and implementation has commenced. Under the new health service model commencing 1 July 2023, two full-time Aboriginal Health Liaison Officers will be employed by Western Health and based at DPFC, to provide seven day a week coverage. The increased presence of Aboriginal Health Liaison Officers will enhance opportunities for Aboriginal women to engage with Aboriginal health professionals should they wish to do so. Justice Health is working with Western Health to explore rostering and on-call arrangements to maximise these opportunities. All reception medical assessments must occur within 24 hours of reception. Currently over half of all receptions into DPFC occur after 4 pm, which may present challenges for Health Service Providers to meet the 24-hour requirement and ensure an Aboriginal Health Liaison Officer is available. Justice Health will work closely with Western Health during the transition-in period, and upon service commencement, to develop alternative options where Aboriginal staff are not available within the required 24 hour-timeframe. These may include a follow-up appointment as soon as practicable. When an offer for a consultation with an Aboriginal Health Practitioner or Health Worker is made but declined, this will be noted in the prisoner’s health record. Those services will also continue to be offered.

That Corrections Victoria and Correct Care Australasia and/or the Health Service Provider at the Dame Phyllis Frost Centre develop and implement a robust procedure for ‘clearance’ of a prisoner (at initial reception or subsequently) from the Medical/Health Centre to a cell elsewhere at Dame Phyllis Frost Centre that requires certification in writing by a medical practitioner that the prisoner is fit to be confined in an unobserved cell.

That Correct Care Australasia and/or the Health Service Provider at the Dame Phyllis Frost Centre, in collaboration with Corrections Victoria and Justice Health, develop and implement clear guidelines to assist custodial and clinical staff to identify a prisoner’s clinical deterioration, including the indicators that must result in an escalation of a prisoner’s care to clinical staff, a medical practitioner or transfer to hospital.

That Justice Health require custodial Health Service Providers to:

I recommend that Correct Care Australasia engage with Victoria's Aboriginal and Torres Strait Islander communities to learn how it can embed culturally safe and culturally appropriate principles into their delivery of health services to Victorian prisoners. This process should be ongoing, guided by Victoria's Aboriginal and/or Torres Strait Islander communities and be conducted in the manner determined by these communities.

I further recommend that Correct Care Australasia:

I recommend that Correct Care Australasia report the deficiencies in care identified in this Finding to its current accreditation providers before it participates in any further tender for the provision of custodial health services in Victoria.

That Corrections Victoria review its practice whereby only two Prison Officers have access to cell keys during the Second Watch overnight at Dame Phyllis Frost Centre and address any impediment to the timely entry to cells that might arise so to ensure prisoner health, welfare and safety.

That the Department of Justice and Community Safety partners with appropriate Aboriginal Community Controlled Organisations to develop and implement a strategy for ongoing cultural awareness training, monitoring and performance review, which is applicable to:

That the Department of Justice and Community Safety develop and implement a policy and deliver training to Corrections Victoria staff about the operation of that policy, to ensure that cultural considerations are incorporated into management of a deceased Aboriginal or Torres Strait Islander person in custody and, to the extent possible, the scene of that person’s passing.