Inquest into the death of Dwayne Johnstone
Deceased
Dwayne Johnstone
Demographics
43y, male
Date of death
2019-03-15
Finding date
2024-08-21
Cause of death
Gunshot wound to the chest and abdomen
AI-generated summary
Dwayne Johnstone, a 43-year-old Aboriginal man, died from a gunshot wound inflicted by a correctional officer during a medical escort from hospital. While in custody on remand, Johnstone experienced an epileptic seizure at court, was assessed and cleared for discharge from hospital, but attempted to escape while being escorted back to the prison van in ankle shackles and handcuffs. Officer A discharged a firearm, with the fatal shot striking Johnstone's chest and abdomen. The inquest identified critical systemic issues: gaps in communication regarding escape risk to escort officers; insufficient training in medical escort scenarios involving shackled prisoners; limited non-lethal weapons available; and legal uncertainty about whether firearm discharge under regulation 303 must comply with the proportionality requirements in regulation 131. The coroner recommended urgent legislative review to clarify and modernise the regulatory framework governing correctional officer firearms use.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Communication gap regarding prisoner's escape risk classification not adequately conveyed to escort officers
- Insufficient training scenario for shackled prisoner escapes during medical escorts
- Limited less-lethal weapons available to escort officers (only firearm, no baton, taser, or OC spray)
- Restrained prisoner (shackled hands and feet) successfully broke free during escort
- Uncertainty in law regarding whether firearm discharge must comply with proportionality requirements in regulation 131
- Prisoner's prior escape history (two previous attempts) not fully absorbed by escort officers
- Medical condition (epilepsy) and emotional state during court appearance
Coroner's recommendations
- That there be an urgent review of the legislation and regulations relating to the use of firearms by officers of Corrective Services NSW, and, in particular, clauses 131 and 303 of the Crimes (Administration of Sentences) Regulation 2014, having regard to the findings in the inquest into the death of Dwayne Johnstone
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