Coroner's Finding: McNAMARA Adam Keneth

Contributing factors

• Police pursuit initiated for minor traffic offence (riding without licence)
• Pursuit was unjustified under police General Orders
• Disproportionate police response to underlying offence
• Pursuit improperly terminated with siren still active
• Deceased unaware pursuit had been terminated
• High-speed police driving on Oxenham Drive in busy shopping centre with pedestrian traffic
• Police vehicle driving dangerously to the public
• Motorcycle inherently more unstable than car in pursuit situations
• Pursuit continued for approximately 650 metres
• Police officer remained within 60 metres of motorcycle at time of crash

Coroner's recommendations

1. Commissioner of Police to provide guidance to police officers regarding circumstances in which it would be inappropriate to pursue motorcyclists
2. Commissioner to consider identifying minor traffic offences that would be inappropriate triggers for pursuit, either within General Order or in training
3. Implementation of incident controller system for pursuits (already substantially addressed in post-2005 General Order revisions)
4. Requirement that pursuing officers immediately stop their vehicle when terminating a pursuit (incorporated in post-2005 versions)
5. Specific reference in General Orders to type of vehicle being pursued (motorcycle) and likelihood of reduced safety
6. Specific reference to non-availability of Incident Controller in pursuit risk assessments
7. Specific reference in General Orders to statutory powers available to establish driver identity, potentially obviating necessity for pursuit
8. Specific reference to solo officer pursuit limitations and need for secondary vehicle
9. Education programs for all police officers regarding high-risk driving and pursuit decision-making