multiple blunt force injuries deliberately inflicted
AI-generated summary
Gayle Elizabeth Woodford, a 56-year-old registered nurse working in Fregon, APY Lands, was abducted and murdered on 23 March 2016 by Dudley Davey, who had a long history of violent sexual offences dating back to age 14. Multiple failures contributed to her death: inadequate on-call nursing protocols requiring nurses to work alone and open security cages to male patients without female companions; absence of police presence in Fregon despite known community violence; failure to identify Davey as a child sex offender registrable under ANCOR when sentenced in 2013; failure to invoke section 23 detention powers despite DCS identifying him as high risk for sexual and violent reoffending; and lack of communication to NHC staff about Davey's dangerous criminal history. The coroner found these systemic failures made the death preventable through appropriate risk management and security protocols.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
occupational and environmental healthemergency medicinecorrectional health
Error types
systemcommunicationdelay
Contributing factors
on-call nursing staff working alone and at night without a second person
security cage protocols not maintained when assessing patients
female nursing staff required to see male patients alone contrary to policy
absence of permanent police presence in Fregon community
failure to identify perpetrator as child sex offender registrable under ANCOR
lack of communication to health workers about dangerous criminal resident
high level of community violence and dysfunction in Fregon
Nganampa Health Council management dismissive of safety concerns raised by nursing staff
Coroner's recommendations
Renewed consideration be given to establishing a permanent police presence in Fregon with officers residing and stationed there
Police General Orders be amended to impose obligation on Police Corrections Section to consider Part 3 Division 5 Sentencing Act 2017 application when advising Parole Board
Police General Orders be amended to impose obligation on Police Corrections Section to consider Part 3 Division 5 Sentencing Act 2017 application and notify Attorney-General if appropriate
Police General Orders be amended to impose obligation on Police Corrections Section to consider Criminal Law (High Risk Offenders) Act 2015 when advising Parole Board
Police General Orders be amended to impose obligation on Police Corrections Section to consider Criminal Law (High Risk Offenders) Act 2015 application and notify Attorney-General if appropriate
Attorney-General introduce legislation to impose obligations on SAPOL, Department for Correctional Services and Parole Board to advise Attorney-General when a prisoner should be considered for section 57 Sentencing Act 2017 application
Department for Correctional Services staff reminded of DCS Local Operating Procedure regarding serious repeat sexual offenders and obligations concerning section 57 Sentencing Act 2017
Nganampa Health Council establish processes ensuring health practitioners are accompanied by responsible person on any callout regardless of time of day or night
Nganampa Health Council amend policies to ensure presentations of persons seeking services are not made by direct approach to health practitioner's home address
State Government review Health Practitioner Regulation National Law (South Australia) Act 2010 provisions regarding second responders for presentations at practitioner's home and journey accompaniment
State Government consult with APY communities regarding release of high-risk offenders to APY Lands, including precluding residence, placement of conditions, and provision of advice to service providers
No person subject to extended supervision order under Criminal Law (High Risk Offenders) Act 2015 should reside or be present on APY Lands
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