Finding into death of John Kennard
Deceased
John Kennard
Demographics
39y, male
Date of death
2019-04-05
Finding date
2022-04-20
Cause of death
Injuries sustained in a fall from a height
AI-generated summary
John Kennard, aged 39, died from injuries sustained falling from a fourth-floor balcony while attempting to escape police executing a bench warrant for his arrest. Police officers allowed him to return to his apartment unaccompanied to change clothes, compromising their ability to monitor and assess him during the critical three minutes before he jumped. Although officers had assessed him as calm and compliant, they were unaware of his prior convictions for escape and his knowledge of facing an 18-month prison sentence. The coroner identified significant procedural failures: police should have maintained continuous supervision (e.g., having one officer accompany him into the apartment) to comply with their duty of care under the Victoria Police Manual principles requiring continual monitoring and assessment of persons in custody. While the coroner acknowledged prevention opportunities and room for improvement, the death could not be established as preventable to the required legal standard, as Mr Kennard made the ultimate decision to attempt escape.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Police officers allowed deceased to return to apartment unaccompanied while in custody
- Loss of continuous monitoring and assessment of person in police care for approximately three minutes
- Officers unaware of deceased's prior convictions for escape
- Officers unaware of deceased's knowledge of facing 18-month prison sentence
- Initial risk assessment not followed by ongoing risk assessment during critical period
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