Inquest into the deaths of Jebriel Dandan and Seiffedine Malas

Contributing factors

• high-speed driving by police vehicle without activation of lights and sirens during speed check
• prioritisation of evidence gathering (speed check) over community safety
• delayed activation of emergency warning devices
• delayed reporting of pursuit to radio dispatch (32-second delay)
• driver impairment from cocaine, cannabis, tramadol at supra-therapeutic levels, and benzodiazepines
• driver's disqualification status and operation of prohibited vehicle (P1 provisional licence)
• insufficient governance and oversight of high-speed police operations
• lack of explicit communication between police officers regarding speed check decision
• police training emphasis on 'best evidence gathering' over early direction to stop

Coroner's recommendations

1. That the SDROG be amended to provide either that where (a) the police vehicle's speed exceeds a specified threshold or (b) the observed or estimated speed of the target vehicle is more than double that of the posted limit, officers must activate warning devices (lights and sirens) and give an immediate direction to stop, rather than proceeding with a 'speed check'. The policy should expressly state that at such speeds the priority is to alert other road users to the police vehicle's presence in order to expressly prioritise community safety, risk education and early intervention, rather than 'best evidence gathering'.
2. That the SDROG be amended to expressly require an explicit verbal check between driver and any offsider (eg. 'speed check vs direction to stop') before commencing or continuing speed check to enable both occupants (if applicable) to expressly turn their mind to the issue, which would provide a further check and/or balance in terms of the rationality or reasonableness of the decision.
3. That once these amendments are made to the SDROG, that a scenario-based practical training module be developed and rolled out for Highway Patrol, Silver and Gold certified officers that (a) prioritises risk reduction and early directions to stop over evidence gathering, (b) contains the relevant speeds at which a speed check is to be abandoned, and (c) includes the communication protocol subject of Recommendation 2. Any training should expressly temper the current emphasis on collecting the 'best evidence' in priority to giving a direction to stop at the earliest available opportunity.
4. Even if changes to the SDROG are not made, officers be practically trained on the Dynamic Risk Assessment requirements introduced in the SDROG, including worked examples of whether that Dynamic Risk Assessment contraindicates the necessity of a speed check and warrants immediate activation of lights and sirens as a direction to stop.