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Coroner's Finding: WOODFORD Gayle Elizabeth

Deceased

Gayle Elizabeth Woodford

Demographics

56y, female

Date of death

2016-03-23

Finding date

2021-04-15

Cause of death

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
  • failure to apply section 23 (now section 57) detention powers despite high-risk assessment
  • 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

  1. Renewed consideration be given to establishing a permanent police presence in Fregon with officers residing and stationed there
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. Department for Correctional Services staff reminded of DCS Local Operating Procedure regarding serious repeat sexual offenders and obligations concerning section 57 Sentencing Act 2017
  8. Nganampa Health Council establish processes ensuring health practitioners are accompanied by responsible person on any callout regardless of time of day or night
  9. Nganampa Health Council amend policies to ensure presentations of persons seeking services are not made by direct approach to health practitioner's home address
  10. 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
  11. 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
  12. No person subject to extended supervision order under Criminal Law (High Risk Offenders) Act 2015 should reside or be present on APY Lands
Full text

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