Coroner's Finding: BRADFORD Steven Michael

Contributing factors

• police pursuit at excessive speed in speed-restricted zones
• officer failed to conduct proper risk assessment before and during pursuit
• officer did not obtain registered owner details available in police records
• officer pursued motorcycle for traffic offences in areas of public risk
• motorcycle's high performance capabilities exceeded rider's experience level
• rider's belief that police were still pursuing him at point of collision
• lack of incident controller oversight during solo pursuit
• failure to terminate pursuit when risks outweighed benefits
• failure to implement alternative investigation methods

Coroner's recommendations

1. Commissioner of Police establish a panel to investigate appropriateness of pursuing motorcyclists at high speed
2. Commissioner of Police amend General Order on high risk driving to include circumstances for/against pursuing motorcycles, reference to registered owner identity relevance, reference to alternative investigation powers, and address sole officer pursuit situations
3. Commissioner of Police devise education programs on amended General Order topics for delivery to all police officers
4. Government Ministers consider legislation preventing registration of vehicles to persons not licensed to drive that vehicle type
5. Government Ministers consider legislation making it an offence for registered owner to knowingly permit unlicensed person to operate the vehicle
6. Government Ministers consider legislation penalising failure to stop when directed by police with minimum licence disqualification served consecutively to other disqualifications
7. SAPOL request Transport SA re-examine Learner Approved Motorcycle Scheme to restrict learner riders from overly powerful motorcycles
8. SAPOL approach Transport SA to examine legislation preventing learner riders from purchasing or registering motorcycles they are not permitted to ride
9. SAPOL approach Transport SA to ensure consistent accredited driver training, testing and licensing across the state
10. SAPOL require all Sworn and Non-Sworn members in country communication rooms undertake approved SAPOL radio procedures communication course
11. Port Lincoln Police Station functionality and incident management reviewed by Officer in Charge West Coast Local Service Area, audited by Service Enhancement Branch