Inquest into the Death of Maureen MANDIJARRA

Contributing factors

• poorly controlled diabetes mellitus
• recurrent skin and soft tissue infections
• chronic alcohol abuse
• homelessness and inability to self-care
• high level of intoxication at arrest
• inadequate health assessment on custody admission
• failure to recognize medical warnings on police information systems
• inadequate and non-compliant cell checks
• failure to take detainee to hospital for medical assessment
• failure to provide proper monitoring of high-risk detainee
• possible septicaemia with bacteraemia

Coroner's recommendations

1. Parliament consider the abolition of the power to arrest and detain an intoxicated person for street drinking where the police officer reasonably suspects the person will continue street drinking unless the person is arrested
2. As an alternative to abolition, arrest of an intoxicated person under s119(1) of the Liquor Control Act 1988, read together with s128(3) of the Criminal Investigation Act 2006, for street drinking, be a last resort
3. The WAPOL Manual be amended to specify that detention in a lock-up be a last resort in cases where an intoxicated person is apprehended under the Protective Custody Act 2000 in order to protect their health or safety, or arrested for street drinking
4. The WAPOL Manual be amended to provide that a welfare screening of an intoxicated person for the purpose of admission to custody in a lock-up is not complete unless the person has had a health assessment by a nurse, or if a nurse is not available and present, a health assessment at the hospital. This is particularly important in the case of a proposed overnight detention
5. At every police station where detainees are held, there must be a dedicated lock-up keeper. Alternatively that a minimum of two officers are rostered for custodial care duties at any time
6. A mandatory training course on the roles and responsibilities of lock-up keeper/supervisor be developed and introduced across Western Australia
7. The Western Australia Police Service develops its cross-cultural diversity training to address mandatory initial and ongoing cultural competency training for police officers dealing with Aboriginal persons
8. The Western Australia Police Service develops its training for police officers transferred to locations with a significant Aboriginal population to receive comprehensive cultural competency training tailored to that location
9. Parliament consider whether legislative change is required to allow medical clinicians to provide the Western Australia Police Service with sufficient medical information to manage a detainee's care whilst in police custody
10. A policy be introduced by the Western Australia Police Service requiring police to contact the Aboriginal Visitors Scheme once a decision has been made to detain an Aboriginal offender in a police lock-up
11. The State Government give consideration as to whether a state-wide 24 hours per day, seven days per week Custody Notification Service based upon the New South Wales model ought to be established in Western Australia
12. The lock-up procedure manual be amended to make reference to: greater monitoring for detainees with repeated hospital attendances; new or changing symptoms in unwell detainees warranting medical review; drug and alcohol use as risk factors for serious illness; and requirement that unconscious or not easily rousable detainees be immediately conveyed to hospital by ambulance