Inquest into the death of Peter Bernard Woodcroft

Contributing factors

• Inadequate information transfer from Telstra operator to PoliceLink regarding caller's ability to speak and audible moaning
• CAD message terminology ('nil req for pol', 'talking in the background', ambiguous 'moan' reference) that conveyed low urgency and was potentially misleading
• Dispatcher failed to re-broadcast priority 3 incident per policy; failed to escalate after 30 minutes
• Responding police officers treated CLI (Caller Line Identification) calls as routine based on prior experience of 'false alarms'
• Officers Morony and Sanders did not attend despite proximity to location; returned to station prioritising end-of-shift tasks without notifying oncoming shift
• Oncoming officers Botha and Field delayed attendance due to other priority jobs and routine duties (intelligence meeting)
• Unknown Triple Zero call history—11 previous cardiac/respiratory emergency calls were not accessible to responders
• Medical condition: congestive heart failure, ischaemic heart disease, atrial fibrillation, COPD, emphysema; non-compliance with diuretic medication

Coroner's recommendations

1. Table for consideration at the National Emergency Communications Working Group the development of a system allowing ready access to: (a) audio recordings of Triple Zero calls captured by Telstra; (b) a caller's Triple Zero call history as held by Telstra; and (c) a location's previous Triple Zero call history as held by each Emergency Services Operator, where permitted by privacy legislation