Inquest into the death of Dale Walkinshaw
Deceased
Dale Scott Walkinshaw
Demographics
23y, male
Date of death
2016-09-19
Finding date
2017-11-21
Cause of death
self-inflicted hanging
AI-generated summary
Dale Walkinshaw, a 23-year-old male, died by self-inflicted hanging in a police caged vehicle while being transported to hospital for medical clearance following his arrest for drink-driving. He used his bootlace, attaching it to the cage mesh and around his neck. The coroner found that police had identified the problem of severely limited visibility into caged vehicles following a 2012 death, conducted a successful CCTV trial in 2013, and made recommendations for rollout. Despite these recommendations, the system was never installed, leaving a critical safety gap. At least 16 self-harm attempts occurred in caged vehicles between 2012-2016. The coroner found system failures in critical incident analysis and risk assessment. While Dale was vulnerable and distressed following a crash, under the influence of alcohol and MDMA, and worried about a passenger's injuries, appropriate installation of visibility monitoring could have prevented his death. The coroner was critical of the failure to implement a relatively inexpensive solution despite clear evidence of risk.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Clinical conditions
Contributing factors
- severely limited visibility into police caged vehicle
- failure to install CCTV system despite 2013 recommendations
- intoxication with alcohol and MDMA
- vulnerability and distress following crash
- concern for injured passenger
- anxiety about criminal consequences
- inadequate police risk assessment and incident analysis systems
- lack of appropriate monitoring during transport
Coroner's recommendations
- The Commissioner of Police should review police risk registers to ensure they reflect appropriate risks with mitigation treatments for each identified risk
- The Commissioner of Police should ensure ongoing analysis of all critical incidents and near misses to ensure that the actual level of risk is appreciated
- The Commissioner of Police should ensure rollout of an appropriate camera system to enable front line police officers to observe persons in the cage of caged vehicles at all times
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