Finding into death of Stephen Arthur Niit

Contributing factors

• failure to communicate suicidal ideation expressed to Pine Lodge Clinic to police
• failure to perform mandatory half-hourly checks on intoxicated detainee
• failure to remove potential ligature points from cell and exercise yard
• failure to remove dog collar that was fashioned into noose
• leaving cell door open to exercise yard with accessible hanging point
• distraction of police officer taking handover report at scene
• allowing dog to accompany detainee in cell
• limited information transfer from off-duty police officer to attending sergeants
• unusual presentation of intoxicated person as jovial rather than aggressive reducing perceived risk
• complacency in applying established custody procedures

Coroner's recommendations

1. Eliminate all hanging points and ligature attachment points in police cells and exercise yards. Echuca exercise yard hinges should be replaced with anti-ligature design hinges; de-commission exercise yards if secure alternatives cannot be designed.
2. Strictly enforce the Victoria Police Manual and Echuca Standard Operating Procedures for management of intoxicated detainees, with mandatory half-hourly personal checks and verbal rousing - no exceptions for compassionate reasons.
3. Institute an 'alert' process to be widely broadcast and disseminated among Victoria Police members providing information about deaths and 'near-misses' in police custody, listing specific procedural failures to reinforce compliance, leaving nothing to discretion.
4. Clarify to all Victoria Police members that intoxication is not a barrier to exercising Section 10 Mental Health Act powers or transferring a person to a mental health facility for assessment.
5. Provide training and disseminate information about actual cases and consequences of non-compliance with custody procedures, emphasizing that tragic outcomes can occur during daily duties.
6. Ensure protocols between Victoria Police and Department of Health clearly establish procedures for identifying vulnerable persons and that mental health information is promptly communicated when a person is in custody.
7. Review and strengthen communication procedures between mental health facilities (like Pine Lodge Clinic) and police when a person expressing suicidal ideation comes into police custody.