Tanya Day inquest – summary of findings
Inquest into the death of Tanya Louise Day (COR 2017/6424), Findings, Coroner English, 9 April 2020
On 9 April 2020, the Coroner handed down her findings in the inquest into the death of Ms Tanya Louise Day.
Ms Day died after sustaining a serious head injury in a police cell on 22 December 2017.
On 5 December 2017, during her train journey, Ms Day was approached by a V/Line train conductor. He called the police, Ms Day was ejected from the train and arrested for being drunk in a public place. Ms Day was taken to Castlemaine police station and detained in a police cell. Despite the requirement that she be physically checked every 30 minutes, this did not happen. The CCTV footage shows that at around 5:00pm Ms Day fell and hit her head on a concrete wall of the police cell.
When a physical check takes place at 8:03 pm, police notice a dark, oval-shaped bruise on Ms Day’s forehead. An ambulance is called and Ms Day was then taken by ambulance to Bendigo hospital. A scan revealed a massive bleed on Ms Day’s brain and she was flown by helicopter to St Vincent’s Hospital in Melbourne, where she underwent emergency surgery. Ms Day died seventeen days later.
On 25 June 2019, the Coroner made a ruling on the scope of the coronial inquest into the death of Ms Day and said that she would “allow witnesses to be questioned as to whether racism played a part of their decision making, including Ms Day’s treatment, options considered, their motivations and potential unintended effects of their decision making.”
The coronial inquest commenced on 26 August 2019 and ran over a number of weeks. Final arguments were heard in November 2019.
Key findings
Cause of death
The official cause of death was a left cerebral haemorrhage of traumatic origin in a woman with liver cirrhosis. While the Coroner said she could not make a finding that the death was preventable, she said there was an opportunity lost for Ms Day’s survival and “there was potentially an omission to obtain timely, appropriate medical care which impacted on her death.”
Treatment by V/Line
The Coroner found that the decision-making process of the V/Line train conductor – who formed the view that Ms Day was ‘unruly’ and organised for the police to attend the train station – was influenced by Ms Day’s Aboriginality and the train conductor’s unconscious bias. This was in part because Ms Day was the first sleeping passenger ever removed from a train by that V/Line train conductor.
Treatment by Victoria Police
The Coroner found that the decision of the police to arrest Ms Day was not influenced by her Aboriginality, and that once they formed the view that it was unsafe to leave her sleeping on the train, arrest was the only viable option. The Coroner also found that the decision to take Ms Day to the Castlemaine police station, instead of the hospital, while not in accordance with the relevant guidelines, was also not influenced by her Aboriginality.
The findings of the Coroner did, however, detail a “culture of complacency regarding intoxicated detainees” within Victoria Police and found that there is a systemic failure to recognise the medical dangers of intoxication and comply with the mandatory terms of the governing policy and procedures regarding the management of persons in care or custody. This shows “the power of stereotype and its resistance to correction.”
The Coroner also found that the physical checks conducted by the police on Ms Day were “illusory” and that the police officers did not take proper care of Ms Day’s safety, security, health and welfare as required by the Victoria Police Manual and the Standard Operating Procedures.
The Coroner notes that if the physical checks had been done by the police in accordance with the relevant requirements, Ms Day would have been checked 10 minutes after her fall.
The Leading Senior Constable was found by the Coroner not to be a credible witness and the findings noted that the accuracy of his custody module entries (regarding the observation and monitoring of Ms Day) are concerning.
The Victorian Charter of Human Rights and Responsibilities Act 2006 is relevant to how police carry out their duties, including “ensuring appropriate monitoring and supervision of people in detention and providing appropriate medical care”. The Coroner made a finding that Ms Day was “not treated with humanity and respect for the inherent dignity of a human person as required by the Charter”.
Treatment by Ambulance Victoria
The Coroner found that the treatment of Ms Day by the first Ambulance Victoria paramedic who attended the Castlemaine police station was “anchored” in her quickly formed view that she was intoxicated. The Coroner accepted evidence that the ambulance officer’s care for Ms Day revealed a “number of deficiencies” but found that no specific action taken by the paramedics impacted on Ms Day’s death.
No findings were made regarding whether Ms Day’s Aboriginality had influenced her treatment by paramedics, but the Coroner noted that Ambulance Victoria apologised to the Day family and gave evidence that the organisation is trying to improve cultural safety for Aboriginal people.
The Coroner made it clear that she preferred the evidence given by members of Ambulance Victoria to conflicting evidence provided by the Leading Senior Constable.
Notification to DPP of possible indictable offence
The Coroners Court is not able to determine guilt in relation to criminal offending, but the Coroner did find that the totality of the evidence supported a belief that an indictable offence may have been committed. Accordingly, the Coroner directed that the Director of Public Prosecutions be notified.
Throughout the inquest, the Day family had submitted that an offence of negligent manslaughter may have been committed by the Sergeant and Leading Senior Constable involved in Ms Day’s death, who the Coroner found failed to monitor and observe Ms Day in accordance with the relevant guidelines.
Recommendations
The findings make 10 recommendations, which are that:
The Victorian Government decriminalise the offence of public drunkenness. There is no justification for the offence of public drunkenness to remain in force “some 30 years” after the Royal Commission Aboriginal Deaths in Custody had recommended its abolition. The Coroner had previously foreshadowed making this recommendation and, on 22 August 2019, the Victorian Government announced that it will abolish the offence and replace it with a public health response.
The Victorian Government legislate to make it clear that the Coroner is directing the coronial investigation, rather than relying on the current arrangements of convention with police. This is in line with recommendation 29 of the Royal Commission into Aboriginal Deaths in Custody and recommendation 42 of the Victorian Parliamentary Law Reform Committee Report.
V/Line review training materials to include input from the Aboriginal and Torres Strait community about unconscious bias and provide training for staff as to how to reduce the impact of unconscious bias in decision making.
V/Line request the Victorian Equal Opportunity and Human Rights Commission conduct a review of the compatibility of its training materials with the human rights set out in the Charter of Human Rights and Responsibilities Act 2006.
Victoria Police review the Victoria Police Manual and amend it to include a falls risk assessment for people in custody whose balance may be affected by alcohol, drugs or illness.
Victoria Police review their training and education regarding the Royal Commission into Aboriginal Deaths in Custody and its recommendations.
Victoria Police implement training for all Victoria Police regarding the Victoria Police Manual and local standard operating procedures regarding the mandatory requirements applicable for the safe management of persons in police care or custody.
Victoria Police implement training regarding the medical risks of people affected by alcohol.
Victoria Police request the Victorian Equal Opportunity and Human Rights Commission conduct a review of the compatibility of its training materials with the human rights set out in the Charter of Human Rights and Responsibilities Act 2006.
The current volunteer model for the Aboriginal Community Justice Panel (ACJP) 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 ACJP with both Victoria Police and the Victorian Aboriginal Legal Service (VALS).
Read the full findings of the Coroner.
Watch the Coroner deliver a summary of her findings.