Finding into death of GC

Contributing factors

• Long-standing schizophrenia and dissocial personality disorder
• Release from prison without parole conditions or mandatory mental health engagement
• Limited success in engaging deceased with community mental health services post-release
• Police pursuit initiated for relatively minor traffic offence
• Police pursuit continued beyond prudent termination points
• Deceased's unpredictable and escalating driving behaviour
• Entry onto freeway exit ramp travelling in wrong direction
• Possible mental health crisis or altered mental state at time of incident
• Possible drug intoxication (THC and oxazepam detected at post-mortem)

Coroner's recommendations

1. Police should never pursue a vehicle simply because it is fleeing. A pursuit should only be undertaken where police hold a pre-existing belief on reasonable grounds that intercepting the vehicle is necessary to prevent a serious risk to public health and safety or in response to a serious criminal offence involving serious harm
2. The Victoria Police risk assessment model for police pursuits should be redeveloped with an alternative model (such as the 'traffic light model') to guide police as to what weight should be given to particular risk factors
3. Implementation of clearer criteria that must be met before a pursuit can be conducted
4. Implementation of a clear requirement that a pursuit must not be initiated in ordinary circumstances for any property or minor traffic offence
5. Implementation of a clearer decision-making tool and risk assessment guide in the form of a flow chart
6. Police members involved in deaths or serious incidents should be separated prior to statements being taken, to preserve the integrity of the investigation