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Government of Western Australia State Coat of Arms
Coroner's Court of Western Australia

Government of Western Australia State Coat of Arms
Coroner's Court of Western Australia

Inquest Findings

Home →Inquest Findings→Inquest Findings 2017→Mandijarra, Maureen

Inquest into the Death of Maureen MANDIJARRA

Inquest into the Death of Maureen MANDIJARRA

Delivered on : 31 March 2017

Delivered at : Perth

Finding of : State Coroner

Recommendations : Yes

RECOMMENDATION 1 – ABOLITION OF ARREST AND DETENTION FOR STREET DRINKING

I recommend that Parliament consider the abolition of the power to arrest and detain an intoxicated person for street drinking where the police officer reasonably suspects the person will continue street drinking unless the person is arrested.

RECOMMENDATION 2 – ARREST A LAST RESORT FOR STREET DRINKING

As an alternative to Recommendation 1, I recommend that arrest of an intoxicated person under s 119(1) of the Liquor Control Act 1988, read together with s 128(3) of the Criminal Investigation Act 2006, for street drinking, be a last resort.

RECOMMENDATION 3 – DETENTION A LAST RESORT FOR STREET DRINKING

I recommend that the WAPOL Manual be amended to specify that detention in a lock-up be a last resort in cases where an intoxicated person is apprehended under the Protective Custody Act 2000 in order to protect their health or safety, or arrested under the Liquor Control Act 1988, read together with section 128(3) of the Criminal Investigation Act 2006, for street drinking.

RECOMMENDATION 4 – HEALTH ASSESSMENT FOR INTOXICATED DETAINEES

I recommend that the WAPOL Manual be amended to provide that a welfare screening of an intoxicated person for the purpose of admission to custody in a lock-up is not complete unless the person has had a health assessment by a nurse, or if a nurse is not available and present, a health assessment at the hospital. This is particularly important in the case of a proposed overnight detention.

EXTANT RECOMMENDATIONS

A number of extant recommendations that have been made in the findings on inquest into the death of Ms Dhu finding apply equally to Ms Mandijarra’s case, using the numbering in that finding:

Recommendations 1 and 2 – in connection with dedicated lock-up keepers and mandatory training on their roles and responsibilities;

I recommend that at every police station where detainees are held, there must be a dedicated lock-up keeper. Alternatively that a minimum of two officers are rostered for custodial care duties at any time.

I recommend that a mandatory training course on the roles and responsibilities of lock-up keeper/supervisor be developed and introduced across Western Australia and that a component of the training be undertaken face-to-face. Successful completion of the course ought to be mandatory before an officer can be assigned lock-up keeper/supervisor duties.

Recommendations 3 and 4 – in connection with the development of the Western Australia Police Service’s cross-cultural diversity training;

I recommend that the Western Australia Police Service develops its cross-cultural diversity training to address the following:

  1. That there be mandatory initial and ongoing cultural competency training for its police officers to assist in their dealings with Aboriginal persons and to understand their health concerns;
  2. That Aboriginal persons be involved in the delivery of such training;
  3. That successful trainees should be able to demonstrate cultural competency – that is a well-developed understanding of Aboriginal issues and the skills to deal effectively with Aboriginal communities; and
  4. That the initial training and at least a component of the ongoing training is to be delivered face-to-face.

I recommend that the Western Australia Police Service develops its training for police officers who are transferred to a new police station to address the following:

  1. That it be a standard procedure for all police officers transferred to a location with a significant Aboriginal population to receive comprehensive cultural competency training, tailored to reflect the specific issues, challenges and health concerns relevant to the location;
  2. That members from the local Aboriginal community be involved in the delivery of such training, and that it be ongoing to reflect the changing circumstances of the location; and
  3. That the initial training and at least a component of the ongoing training is to be delivered face-to-face.

Recommendation 5 – in connection with the provision by medical clinicians to police of sufficient medical information to manage a detainee’s care while in police custody;

I recommend that Parliament consider whether legislative change is required in order to allow medical clinicians to provide the Western Australia Police Service with sufficient medical information to manage a detainee’s care whilst in police custody. Allied to this is a consideration of the safeguards concerning that information.

Recommendation 9 - in connection with police contacting the Aboriginal Visitors Scheme once a decision has been made to detain an Aboriginal offender in a lock-up, and/or take an Aboriginal detainee for medical treatment;

I recommend that a policy be introduced by the Western Australia Police Service that requires the police to contact by telephone the Aboriginal Visitors Scheme once a decision has been made to detain an Aboriginal offender in a police lock-up. In addition, any APLO attached to the station should also be made aware by police that they may contact the Aboriginal Visitors Scheme at any time on behalf of a detainee.

Furthermore, once a decision has been made to take an Aboriginal detainee for medical treatment, contact by telephone must be made by the police to the Aboriginal Visitors Scheme advising it of that fact, the name of the detainee and which hospital or medical treatment facility the detainee is being taken to.

Recommendation 10 – in connection with consideration of the introduction of a Custody Notification Service;

I recommend that the State Government gives consideration as to whether a state-wide 24 hours per day, seven days per week Custody Notification Service based upon the New South Wales model ought to be established in Western Australia, to operate alongside and complement the Aboriginal Visitors Scheme.

Recommendation 11 – in connection with amendments to the WAPOL Manual in relation to the care of detainees, to assist with better recognising risk factors.

I recommend that the lock-up procedure manual be amended to make reference to the following in relation to the care of detainees:

  • A greater degree of regular monitoring should be provided to any detainee complaining of severe symptoms that necessitate repeated hospital attendances within a short space of time;
  • New or changing symptoms in an unwell detainee may signify deterioration warranting medical review;
  • Drug and alcohol use are risk factors for serious illness, and can both mimic and obscure the symptoms of serious illness; and
  • A person found to be unconscious or not easily rousable whilst in police custody must be immediately conveyed to hospital by ambulance.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was arrested and detained at the Broome Lock-up in connection with street drinking. She was heavily intoxicated when she was admitted into custody and in the early hours of the morning on 30 November 2012 she was found unresponsive by police as she lay on a mattress in the police cell.  She was 44 years old at the time of her death.  The provisions of The Coroner’s Act 1996 require the death of a person while in police custody be examined by way of inquest, and the supervision, treatment and care of the deceased while in custody be commented upon.

The deceased’s suffered pre-existing conditions included poorly controlled diabetes. She also suffered from recurrent infections.   The severity of these conditions was exacerbated by her alcoholism and homelessness.  At the time the deceased was apprehended police did not appreciate how fragile her overall health was and they admitted her into custody.  Unfortunately the deceased’s health deteriorated overnight and she suffered a catastrophic collapse.

 The police officers responsible for ensuring Ms Mandijarra’s safety and welfare failed to conduct the regular cell checks as required for the Broome lock-up. Evidence at the inquest reflected that these failures were occasioned by a lack of understanding of cell check procedures and the impact of both workloads and individual work practices.  However the State Coroner was not satisfied that cell checks alone, even if conducted at requisite intervals, would have been likely to ensure the deceased’s safety and welfare.

Realisation only monitoring in a hospital seeing would have been likely to detect the severity of the deceased’s deterioration. Whilst the proper and appropriate course would have been to take Ms Mandijarra to hospital, given the uncertainties surrounding the cause of death, any comment as to the likely outcome would be speculation.  The State Coroner commented that the police’s supervision, treatment and care of Ms Mandijarra was deficient and fell below the standards that should ordinarily be expected of the police.  The State Coroner was satisfied that there was no evidence that suggested that Ms Mandijarra’s death appeared to have been caused, or contributed to, by any action of the police.

The State Coroner found that the deceased died on 30 November 2012. The cause of death is unascertained (consistent with Streptococcus dysgalactiae and Stephylococcus aureus septicaemia in a woman with diabetes mellitus) and death occurred by way of Natural Causes.

Catch Words : Aboriginal Death in Custody: Cell checks for detainees; Intoxication; risks of detaining intoxicated persons: Natural Causes.

 


Last updated: 4-Oct-2024

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