Inquest into the Death of Shionah Violet Teneille CARTER

Delivered on - 12 September 2014

Delivered at - Perth

Finding of - E F Vicker, Deputy State Coroner

Recommendations - Yes

Orders/Rules - N/A

Suppression Order - N/A

Summary - The deceased was a 26 year old female who died on 15 August 2010 from a combined result of a number of injuries sustained during a prolonged altercation with her partner.

The inquest examined police protocols and procedures surrounding 000 calls and whether any police action contributed to the death of the deceased.  The Coroner found that the deceased’s partner both caused and contributed to her death.  It was possible, but unknown, earlier medical intervention could have prevented her death.

The Deputy State Coroner made two recommendations –

The WAPol Police Communications Centre include the voice call from 3:21am on 15 August 2010, as a practical case study for 000 call takers to use in their initial training to become 000 call takers.  Consideration should also be given to using the call as a refresher case study for call takers in certain circumstances.


In furthering the development of computer aided dispatch (CAD), WAPol assess it for its capability to include an automated system of electronic alerts, where information relevant to possible dangers at an address, or posed by a caller, can be automatically fed between the CAD job created by a 000 call taker, and the 000 call taker’s screens, via IMS.  Alerts should be linked to the confirmed CLI data (name, address and number) and may include such things as previous domestic violence incidents at the address, or those involving the caller; previous calls from the number to 000 within the last 15-24 hours; violent offences attracting imprisonment (linked to the caller, subscriber, any other names entered into CAD by the call taker). [This system would supplement the current ad hoc reporting of matters of concern by officers external to the PCC].  This should be done with a view to the function being implemented to the extent possible within the core functionality of the future system. 

The Deputy State Coroner found that death arose by way of Unlawful Homicide

Catch Words - 000 Calls – s.22(1)(b) Coroners Act 1996 – s.53(2) Coroners Act 1996 – Training - methylamphetamine


Last updated: 2-Feb-2024

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