Inquest into the death of Tyrone Adams
Deceased
Tyrone Raymond Adams
Demographics
22y, male
Date of death
2018-09-27
Finding date
2022-12-09
Cause of death
Multiple injuries to the chest, abdomen and limbs
AI-generated summary
Tyrone Adams, age 22, died in a motor vehicle collision on the M1 Motorway following a police pursuit. The initial pursuit was initiated based on questionable reasonable suspicion to stop a hire vehicle. The coroner found the decision to pursue was not properly justified under Safe Driving Policy, which lacks clear thresholds requiring officers to assess whether a pre-existing serious risk to health/safety justifies the inherent dangers of pursuit. The deceased was affected by methylamphetamine at the time. Key clinical lessons include: police must balance pursuit dangers against actual risks posed; officers require better guidance on proportionality of enforcement actions; drug-affected drivers present elevated risks requiring different police response strategies; and policies must explicitly mandate consideration of whether dangers inherent in pursuit exceed dangers being prevented.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Police pursuit decision-making without adequate safety threshold
- Ambiguous Safe Driving Policy provisions (Parts 7.2.1, 7.2.3, 7.2.9)
- Inadequate consideration of seriousness of original offence
- Questionable reasonable suspicion for initial vehicle stop
- Possible unauthorised re-engagement of pursuit
- Methamphetamine intoxication affecting driving ability
- Driver unfamiliar with the vehicle
- High-speed driving on wrong side of motorway
Coroner's recommendations
- Amend Safe Driving Policy to mandate that a pursuit can be commenced only if police are satisfied that a serious risk to the health and safety of a person existed before the decision to intercept or stop the vehicle
- Make clear in Safe Driving Policy terms and training that this serious risk test is the threshold test for police pursuits
- Amend Safe Driving Policy to expressly provide that upon a pursuit being called the relevant pursuit supervisor must ask the pursuing officer to identify the serious risk to health or safety that existed before the decision to intercept or stop the vehicle, and give independent consideration to whether that threshold is met
- Ensure state-wide mandatory training be provided to all NSWPF officers on the threshold test for police pursuits
- Mandate that the serious risk to the health and safety of a person that existed before the decision to stop or intercept a vehicle be recorded for every police pursuit
- Give consideration to amending Body Worn Video Standard Operating Procedures to provide clarity on recording conversations between police officers in circumstances where those conversations have evidentiary value
- Direct that a notification is made via Police Communication and/or by Nemesis reminding officers that telephone calls made to Emergency Services Facilities are recorded
- Give consideration to amending the practical training exercise for police pursuits in the Silver Certification Classification Course to replace the random breath test failure scenario with a pursuit of a driver wanted for violent offences
- Further investigate the use of driver simulators to supplement practical training on urgent duty driving and police pursuits
- Incorporate current information on adverse mental health impacts of police pursuits into video shown to NSWPF recruits undertaking driver training at the Goulburn Academy
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —