Cindy Miller inquest – summary of findings

Inquest into the death of Cindy Leigh Miller (COR 2018/1782)

On 22 January 2021, the Coroner handed down his findings in the inquest into the death of Ms Cindy Leigh Miller in the Coroner’s Court of Queensland.

Ms Miller died in custody at the Ipswich Watchhouse (the Watchhouse) on 21 April 2018.  Ms Miller’s cause of death was ‘mixed drug toxicity’. The Coroner found that it took police at the Watchhouse well over an hour to realise that Ms Miller was unresponsive.

On 20 April 2018, Ms Miller and another person were pulled over by two police officers while driving. Ms Miller had two outstanding warrants and was arrested. Upon searching the car and Ms Miller, the police officers found two hypodermic syringes, several empty small clip seal bags and three Valium tablets. Ms Miller was arrested and taken to the Watchhouse in a police wagon. She was charged with two drug-related offences. 

The arresting police offices had told Ms Miller they did not object to her being granted bail; however, bail was subsequently denied.

Ms Miller was processed at the Watchhouse and at 10.05pm Ms Miller advised police that she wanted to go to sleep for the night. The police officers at the Watchhouse were to check in on Ms Miller every sixty minutes or less. The CCTV footage showed that Ms Miller made no obvious movements after 12.03am and that she was likely deceased from that time.  

At 1.35am on 21 April 2018, the police officer checking Ms Miller could not see any signs of life. The police officer unlocked the cell and physically touched Ms Miller. The Constable alerted the shift supervisor, Sargent Ponting, and 000 was called.

Sargent Ponting was not able to locate a manual resuscitation mask, she did however locate and use the Watchhouse defibrillator which advised a continuation of CPR. The offices started performing CPR and continued to do so until paramedics arrived. Paramedics attempted to resuscitate Ms Miller but were unable to do so. Ms Miller died in the early hours of 21 April 2018.

Key findings

Cause of death

Ms Miller’s autopsy found that her cause of death was mixed drug toxicity. The autopsy revealed that there was a clip seal bag containing methyl amphetamine in Ms Miller’s vagina. The Coroner could not determine whether Ms Miller died from an accidental overdose after intentionally consuming drugs in custody, or whether she had accidently absorbed the drug from the clip seal bag.

From the CCTV footage of Ms Miller’s cell, the Coroner found that Ms Miller made no obvious movements from 12.03am and that she was likely deceased from that time. The Coroner found that the police officer who checked on her at 12.40am was under ‘a mistaken belief’ when he believed Ms Miller to be asleep’. The Coroner found that the police did not find her unresponsive until ‘well over an hour after she stopped making movements.’

The Health Questionnaire

The Queensland Police Service guidelines provide that, as soon as possible after someone enters the Watchhouse, they are to undergo a health check (the Health Questionnaire (the Questionnaire) and Observations Check List). Police officers who administer the Questionnaire do not follow a script and cannot tell people that they will not be charged as a result of their answers. However, the police officers are to inform people that the Questionnaire is for their health and safety and not for the purpose of securing further charges or evidence.

When the police officers completed the Questionnaire with Ms Miller, she did not disclose the consumption or holding of any illicit substances.

The Coroner accepted that it was likely Ms Miller would be aware that informing the police officers that she was in possession of an illegal drug would result in further charges. The Coroner found that it was likely Ms Miller did not disclose or dispose of the drugs in her possession because she was told she would likely be granted bail.

Adequacy of emergency procedure at the Watchhouse

The Coroner observed that only three of the ten staff rostered on the afternoon and evening of Ms Miller’s intake to the Watchhouse had completed first aid or CPR training in the period between July 2017 and the date of Ms Miller’s death.

The Coroner also found that the police officers on duty did not know where the resuscitation masks and face shields were kept in the Watchhouse and that they were not able to be located at the time of Ms Miller’s death. Ms Miller’s airway was not adequately managed during CPR because of this.

Adequacy of CCTV cameras and monitoring facilities

The CCTV camera in Ms Miller’s cell was found to be scratched, smudged and dirty. This meant that the CCTV footage did not capture the rise and fall of Ms Miller’s chest. The Coroner found that CCTV footage is not a substitute for Watchhouse officers personally checking on people in custody; but in any event it is important that the CCTV footage is clear.  

The need for an independent review of police-related deaths

Ms Miller’s family asked the Coroner to consider whether there should be an independent review of how police-related deaths are investigated.

The Coroner found that the current method of investigation is ‘generally effective’ and expressed concern that changes to the current method of investigating police-related deaths may result in delays and less thorough investigations. 

Nonetheless, the Coroner recommended that the Queensland Government consider commissioning an independent review of the current arrangements for the investigation of police-related deaths.  Should the review be commissioned, the Coroner recommended that the following be considered:

• which entity is best placed to assist the coroner in the independent investigation of police-related deaths;

• what oversight is required;

• what associated investigative powers should be provided for in legislation; and

• what resources are necessary for investigations.

The Coroner also flagged that the NSW Parliament recently established a Select Committee into the High Level of First Nations People in Custody and Oversight and Review of Deaths in Custody (the Committee). The Committee is examining the suitability of the oversight bodies that are responsible for inquiries into deaths in custody. The Committee is scheduled to report their findings and recommendations on 31 March 2021.

Recommendations

The Coroner accepted that the Watchhouse had taken steps to ensure that police officers were now up to date with their first aid training, and to ensure CCTV cameras were routinely cleaned and repaired. The Coroner also made the following recommendations:

• The Queensland Police Service consider revising the script that accompanies health questionnaires asked on entry into Watchhouse custody with a view to ensuring that people understand their answers would not result in further charges and are only for the purpose of managing their health needs; and

• The Queensland Government consider whether to commission an independent review of the current arrangements for the investigation of police-related deaths on behalf of the coroner and the oversight of those investigations.

The full case can be read here.

Cassandra Hamill is a graduate lawyer on secondment at the Human Rights Law Centre.