Inquest into the deaths of Shiralee Deanne Tilberoo and Vlasta Wylucki
Deceased
Vlasta Wylucki and Shiralee Deanne Tilberoo
Demographics
female
Date of death
2018-03-01
Finding date
2024-06-18
Cause of death
Vlasta Wylucki: ischaemic heart disease due to coronary atherosclerosis (previous angioplasty-stent). Shiralee Deanne Tilberoo: subarachnoid haemorrhage due to ruptured berry aneurysm.
AI-generated summary
Two women died of natural causes in Queensland police watchhouses but supervisory failures raised serious concerns. Ms Wylucki (50) died from ischaemic heart disease after inadequate cell checks failed to detect her vomiting overnight; had she been checked properly and medical attention sought, there was a potential opportunity for intervention. Ms Tilberoo (49), an Aboriginal woman, died from a ruptured berry aneurysm; although this sudden event was not preventable, inadequate cell checks during the night she died meant her death was not detected for hours. Both cases expose systemic issues: physical cell checks were not conducted to required standards, nursing staff were not available 24/7, and vulnerable prisoners with medical and withdrawal symptoms lacked adequate supervision. The coroner found the QPS policies themselves were appropriate but their implementation failed, and made recommendations for enhanced medical staffing, improved training, reduced watchhouse detention periods, and external oversight.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- inadequate physical cell checks in violation of OPM 16.13.3
- failure to observe prisoner breathing and movement adequately
- absence of 24-hour nursing services in watchhouses
- inability to detect deterioration during night shifts
- cell configuration at Southport Watchhouse obscured observation
- lack of compliance with cell inspection procedures despite officer knowledge
- false custody log entries recording 'no problems detected' when prisoners were seriously unwell
- for Ms Tilberoo: heroin withdrawal not managed optimally due to watchhouse setting limitations
- for Ms Wylucki: medication not reviewed or dispensed after-hours despite cardiac history
Coroner's recommendations
- Queensland Government consider amending section 6(2) of the Corrective Services Act 2006 to reduce the maximum watchhouse detention period from 21 days to 72 hours
- Queensland Government provide additional resourcing to QPS for training of watchhouse officers and specialised police officers
- Queensland Government provide resourcing to jointly enable Queensland Health and QPS to place nursing and/or paramedical clinicians in all Queensland WHs 24/7 (in person or by technological means) with access to clinical information systems
- Following implementation of 24/7 nursing, QPS amend s16.13.1 of the Operational Procedures Manual to provide that initial health assessment of persons in WHs is conducted by a Queensland Health clinician
- Queensland Government provide additional funding to non-government organisations whose core business is support of persons in custody to enhance external accountability and transparency in watchhouses
Full text
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