Finding into death of Nicole Maree Knox-Smith

Contributing factors

• Police pursuit of stolen vehicle driven by heavily drug-intoxicated driver
• Ambiguous and incomplete radio communications regarding pursuit termination
• Radio interference overriding critical safety instruction to 'pull over and let him go'
• Continuation of 'hemming in' operation post-abandonment creating perception of ongoing pursuit
• Driver's acute intoxication with heroin, amphetamine, and benzodiazepines
• Vehicle fuel problems causing unexpectedly slow speed and unpredictable manoeuvres
• Driver's paranoid state and erratic driving behaviour
• Insufficient clarity in post-pursuit policy regarding disengagement from offender

Coroner's recommendations

1. The Chief Commissioner consider developing a set of clear verbal instructions to provide for the type of circumstances that occurred in the management of the post-pursuit phase, particularly when an offending driver crosses the path of police vehicles during a 'hem in' operation
2. The Chief Commissioner consider the feasibility of increasing the duration of the audible tone which signals the abandonment of a pursuit to ensure it is heard by all members
3. Victoria Police should review the practice of Pursuit Controllers working alone (one-up) whilst managing difficult and time-critical decisions
4. Victoria Police should consider amending pursuit policy to clarify what is meant by 'follow the driver' to include reference to maintaining visual contact with the offending vehicle
5. Victoria Police should examine whether the discretion to 'patrol the last known location' should be removed or clarified when the offending vehicle may double back or attempt evasion at low speed on a freeway
6. Victoria Police should consider improved D24 procedures including: communicating location of all units at conclusion of pursuit and seeking confirmation units are stationary; assisting incident controller to deploy units when decision to patrol last known location is taken; advising incident controller of any information suggesting risk of unwitting re-engagement