Inquest into the death of Frederick Alfred McGREGOR
Deceased
Frederick Alfred McGregor
Demographics
69y, male
Date of death
2011-02-25
Finding date
2014-12-09
Cause of death
head injury sustained from assault
AI-generated summary
Frederick McGregor, aged 69, died from head injuries sustained in a violent assault by another detainee while in court cell custody. McGregor was placed in a cell with an 18-year-old who assaulted him after believing McGregor was a sex offender. This belief arose after a police sergeant called McGregor a 'rock spider' (slang for child molester) within earshot. Custody officers failed to read McGregor's custody documents or check system alerts that would have identified his status as a registered sex offender, leading to inappropriate cell placement. The coroner found that had custody managers properly reviewed available documentation and system warnings, McGregor would have been placed separately and likely remained safe. Key lessons include the critical importance of thorough information review during prisoner admission and the consequences of casual, unprofessional language by custody staff.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Failure of custody officers to read custody management documents
- Failure to check OIMS system for prisoner alerts and warnings
- Inappropriate placement of two prisoners in same cell without proper assessment
- Unprofessional language by custody staff alerting detainee to McGregor's status as sex offender
- Lack of completion of admission interview forms (Lodgement and IO forms) before cell placement
- Sergeant Dunn's unprofessional conduct using term 'rock spider' within earshot of other detainee
Coroner's recommendations
- To the Commissioner of Police: disseminate electronically a state-wide memorandum reminding custody managers to read the custody management record, Form 7 and any other custody documents in full
- To the Commissioner of Police: remind custody managers to check all warnings for persons in custody
- To the Commissioner of Police: remind custody managers of the reasons why thorough document review and warning checks are important
Full text
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