Inquest into the Death of Shionah Violet Teneille CARTER

Contributing factors

• Traumatic brain injury with concussion/unconsciousness from prior assault
• Failure to dispatch emergency services following 3:21am 000 call despite hearing sounds of distress
• Intimate partner violence
• Perpetrator drug intoxication (methylamphetamine, alcohol, cannabis)
• Victim's vulnerable state due to head injuries rendering her unable to protect airway

Coroner's recommendations

1. The WAPol Police Communications Centre should include the voice call from 3:21am on 15 August 2010 as a practical case study for 000 call takers to use in their initial training to become 000 call takers. Consideration should also be given to using the call as a refresher case study for call takers in certain circumstances.
2. In furthering the development of computer aided dispatch (CAD), WAPol should assess it for its capability to include an automated system of electronic alerts, where information relevant to possible dangers at an address, or posed by a caller, can be automatically fed between the CAD job created by a 000 call taker, and the 000 call taker's screens, via IMS. Alerts should be linked to the confirmed CLI data (name, address and number) and may include such things as previous domestic violence incidents at the address, or those involving the caller; previous calls from the number to 000 within the last 15-24 hours; violent offences attracting imprisonment (linked to the caller, subscriber, any other names entered into CAD by the call taker). This should be done with a view to the function being implemented to the extent possible within the core functionality of the future system.