Finding into death of Georgie Lopiccolo

Contributing factors

• Failure to communicate suicide warning from LEAP system to custody officers
• Inadequate handover of property removed during search (pantyhose left in plain view without documentation)
• Break in information flow between Criminal Investigations Unit and watch-house/uniform branch
• Reliance on demeanour rather than documented warnings to assess suicide risk
• Visual rather than thorough search at lodgement due to false assurance from previous SOCAU search
• Information overload and de-sensitisation to LEAP warnings
• Understaffing of watch-house (one member sick, three rostered)
• Failure to document removal of pantyhose as ligature risk item
• Supervision gap - no single person had complete information about the person in custody

Coroner's recommendations

1. Chief Commissioner of Police should establish a procedure whereby those brought to police station for questioning and/or in custody are processed through the watch-house upon arrival, with all arrival checks, searches and documentation completed there before proceeding to interview.
2. Alternatively, Chief Commissioner should establish a procedure whereby any property removed during any search is receipted on a document which remains with the person through to release from custody or lodgement in cells.
3. Chief Commissioner should provide further training for members to recognise suicidal or self-injurious intent and to identify ligature or weapons potential of seemingly innocuous items.
4. Chief Commissioner should reinforce the need for better communication, particularly between Criminal Investigation Unit and Uniform Branch around lodgement of prisoners to improve welfare of people in custody.