Inquest into the death of Anne Chantell Millar
Deceased
Anne Chantell Millar
Demographics
21y, female
Date of death
2003-03-28
Finding date
2005-09-02
Cause of death
Multiple blunt trauma with acute alcohol toxicity as a significant contributing factor
AI-generated summary
Anne Chantell Millar, a 21-year-old Aboriginal woman, was beaten to death by her partner Gregwyn Green on 28 March 2003 despite a domestic violence restraining order in place since January 2003. Multiple breaches of the order occurred over the preceding two months, but police failed to consistently enforce it. Key clinical and systemic issues: acute alcohol toxicity was a contributing factor to her death; one officer (Senior Constable Curyer) was working while suffering significant mental illness and depression, taking antidepressant medication, which impaired his judgment; police General Order D7 regarding domestic violence response was not uniformly applied; communication failures between police systems (PROMIS/IJIS) and lack of clear direction from supervisors contributed to enforcement gaps. The death was likely preventable had police properly arrested Green on any of five breaches, particularly on 27 March when he assaulted her at the Palmerston Tavern.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Domestic violence by partner Gregwyn Green
- Acute alcohol toxicity
- Police failure to enforce domestic violence restraining order on multiple occasions
- Inconsistent application of General Order D7 by police officers
- Failure to arrest Green after multiple documented breaches
- Police communications system failures (PROMIS/IJIS discrepancies)
- Lack of clear direction from supervisors to investigating officers
- Senior Constable Curyer working while suffering untreated mental illness and depression
- Inadequate police supervision and oversight of vulnerable officer on public duties
Coroner's recommendations
- Commissioner review circumstances permitting Senior Constable Wayne Anthony Curyer to patrol and contact public on 27 March 2003 while suffering mental illness requiring significant antidepressant medication and psychiatric specialist care
- Commissioner review police procedures and protocols between Police Welfare Division and senior officers responsible for general duties placements to ensure officers suffering mental illness are not subjected to inappropriate stress levels that might endanger themselves or the public
- Commissioner review protocols for release of persons in police custody into hospital care where those persons may have breached a DVO and risk self-discharge; early notification to police by hospital staff of self-discharge could enable early re-arrest and prevention of further DVO breaches
- Commissioner reinforce in every way possible the importance of compliance by police with General Orders pertaining to domestic violence
Full text
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