Inquest into the Death of Harris, Mr
Deceased
Harris, Mr
Demographics
74y, male
Date of death
2010-02-02
Finding date
2013
Cause of death
Ischaemic heart disease in association with coronary artery atherosclerosis
AI-generated summary
Mr Harris, a respected Aboriginal elder aged approximately 74 years, died of ischaemic heart disease with coronary artery atherosclerosis while travelling bush alone on 2 February 2010. He bogged his vehicle, attempted unsuccessfully to extract it in hot conditions, then walked toward the Wilga Road/mine site seeking help. Evidence suggests he suffered a fatal cardiac event while walking, likely after exertion and heat exposure. The coroner found the death resulted from natural causes and was not preventable by police actions. However, systemic lessons emerged: police failed to record telephone calls appropriately in the occurrence book during shift handover, limiting continuity of information. While Derek's initial call was appropriately interpreted as a routine welfare check, the lack of comprehensive recording meant critical information from subsequent calls was not effectively transmitted to field officers. The coroner recommends improved documentation procedures, appropriate assessment of missing person concerns considering age and recent health issues, and basic search and rescue training for remote police stations.
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Specialties
Error types
Clinical conditions
Contributing factors
- severe coronary artery stenosis
- physical exertion in high temperature conditions while attempting to extract bogged vehicle
- advancing age and recent hospitalisations for respiratory illness
- visual impairment (blind in right eye, cataract in left eye) limiting ability to seek help effectively
- travelling alone despite family concerns
Coroner's recommendations
- Any telephone call requiring police action be logged in the occurrence book. Recording information with contact details on a piece of paper alone is not effective communication.
- The occurrence book needs to be used to effectively note details relevant to handover and be positioned where it is accessible to provide continuity of information through shift changes.
- Once there is a concern a person has not been sighted by a time an appropriately informed person believes is critical, the police officer/staff member to whom the concern is expressed must record relevant information by asking appropriate questions to ensure the circumstances of the failure to appear are appreciated. That information will always be relevant to identification issues.
- Where a police officer is aware of an incident which may relate to a missing person, the police officer should take an appropriate missing person report, regardless of the incident. The information can always be used to exclude an identity if it does not relate to the incident in question, and also serves to ensure an appropriate assessment of the circumstances of the missing person.
- All police officers serving in remote locations such as Laverton, Tom Price and Newman should have basic training in search and rescue operations in remote areas. Assessing the basis for family concern is crucial.
Full text
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