Inquest into the death of Delvene Thompson

Contributing factors

• Driver Peter Lynch evaded police after traffic stop
• Failure to classify initial 16-second pursuit as a pursuit under policy
• Lack of incident controller appointment despite complex ongoing police engagement
• Inadequate coordination between police vehicles without clear command structure
• Failure to notify JESCC before conducting traffic apprehension
• Confusion about TDD authorization and approvals
• Attempted 'boxing' manoeuvre conducted by untrained officers in breach of policy
• Failure to terminate pursuit after driver breached red lights at first intersection
• No resolution strategy in place when pursuit commenced on Trower Road

Coroner's recommendations

1. Make it mandatory that deaths arising from or connected to a police pursuit are investigated in the same way as a death in custody is investigated
2. Amend the definitions of pursuit and emergency vehicle driving to remove ambiguity and overlap
3. Give consideration to the circumstances in which it is appropriate to allocate an incident controller (or a person exercising similar oversight) to assist police members carrying out traffic duties, including when TDD is requested, when police are engaging with a hostile vehicle, or when there is a need for a coordinated resolution strategy, and to amend General Orders as necessary
4. Ensure police members are aware of their obligations to notify JESCC before conducting a TRAP and of their obligations to activate their BWV when conducting a TRAP or pursuit
5. Continue to explore ways of improving the video capability of police vehicles, including the feasibility of automatic activation