Finding into death of Antonio Loguancio

Contributing factors

• Media coverage and public identification leading to psychological distress
• Failure to control subject's communication with third parties through multiple mobile phones
• Inadequate involvement of treating psychologist in siege management
• Poor internal police communication and coordination
• Lack of appropriate technical infrastructure (PEEC system unavailable)
• Subject's fear of lengthy imprisonment and return to custody
• Escalating police tactics involving bright lights, loud acoustic devices, police dog deployment
• Subject's antisocial personality disorder and difficulty with authority
• Breakdown in communication between negotiators and dog squad unit

Coroner's recommendations

1. Victoria Police to amend the Victoria Police Manual to include identification of critical risk factors in the risk assessment process for serious sex offenders wanted for breaching Supervision Orders, including: status of current investigations; welfare of victims; impact on perceptions of community safety and welfare; and likely impact on the offender
2. Victoria Police Director of Media and Corporate Communications to contact media outlets to correct false and misleading reports and to request change to reporting style where deemed unnecessarily inflaming a particular situation
3. Australian Press Council to review its Statement of General Principles regarding media interference with active police operations
4. Forensicare to review its policy and procedure pertaining to circumstances in which professional staff have information that may assist authorities to avoid harm, particularly in critically unfolding situations where there is a risk of harm to client and/or others
5. Police to ensure PEEC (Police Emergency and Event Control) logging system is available and functional for critical incidents, rather than resorting to email logs
6. Police to ensure all relevant units (TSU, Dog Squad, CIRT) are included in Incident Management Team meetings to enable contribution of relevant information and receipt of operational updates