Inquest into the Death of Joyce Gladis CLARKE

Contributing factors

• police officer ran toward armed person without maintaining safe distance
• inadequate de-escalation attempt by police
• lack of communication and coordination between attending police officers
• insufficient training in tactical communication and de-escalation
• failure to recognize Clarke had been recently hospitalized as involuntary mental health patient
• lack of mental health follow-up after hospital discharge
• inadequate Aboriginal cultural awareness training for police
• failure to conduct pre-incident mental health assessment before police engagement
• lack of effective containment strategy despite police already cordoning the scene

Coroner's recommendations

1. Establish a dedicated section or branch of WA Police focused on improving relationships with Aboriginal persons, in consultation with Aboriginal communities
2. WA Police provide Aboriginal Cultural Awareness training co-designed and delivered by Aboriginal persons, including face-to-face regular training tailored to regional needs, emphasizing intergenerational trauma, foetal alcohol spectrum disorder, and cultural wellbeing
3. De-brief First Class Constable Cleghorn, Senior Constable Walker, First Class Constable Caracatsanis, Senior Constable Cooney, Senior Constable Bird and Constable McLean by Mr Markham or similar trainer regarding events of 17 September 2019 including de-briefing on cordon and containment, and incorporate scenario-based training from learnings into ongoing WA Police training
4. WA Police continue trialling and considering the future use of new conducted energy weapon platforms such as tasers
5. Health service providers prioritize engagement in nationally agreed development of Implementation Plan for Gayaa Dhuwi (Proud Spirit) Declaration to support culturally safe and responsive health care
6. Discharging health service providers consider notifying local health services (with patient consent) that patient is returning to Country or area where they habitually reside, even without active referral, to ensure continuity of support
7. Director General of Department of Health consult with WA Police to work on sharing relevant mental health information between agencies in way that balances privacy with imminent safety risks
8. Mental Health Co-Response continues to be funded and WA Police consult with stakeholders to revisit the model, exploring ways authorised mental health practitioners can give remote support and advice to police attending mental health crisis incidents
9. WA Police review In-Service Critical Skills training 1, 2, 3 and 5 to assess whether Use of Force training can be integrated with effective communication training, and consider effectiveness of audit processes