Coroner's Finding: Paul Wayne Carter

Contributing factors

• Blood alcohol content of 0.17 at time of death
• Cannabis use
• Acquired brain injury and intellectual disability from chronic solvent abuse
• Brother's sudden death from epileptic seizure earlier that day
• Emotional distress and grief
• Relationship breakdown with girlfriend
• Police decision to leave him on isolated, unlit highway at midnight in winter conditions
• Failure by police to assess Paul's vulnerability and mental state
• Failure to escalate decision to supervisor or seek advice

Coroner's recommendations

1. Victoria Police should consider using the facts of this case as a teaching resource in recruit induction and ongoing police training to develop understanding of expectations for responsible policing and suicide awareness
2. Victoria Police should review what is being taught to recruits and disseminated throughout the organization regarding obligations to members of the public being transported by police when not under arrest or in custody
3. Victoria Police should ensure great caution is exercised in the immediate aftermath of any death in police custody, care or control and that only accurate information is communicated to family and community
4. Victoria Police should consider requesting members directly involved in a death in police custody, care or control to participate in an electronically recorded interview as soon as practicable after the death