A Victorian coroner has referred the 2017 death of Yorta Yorta woman Tanya Day in police custody to prosecutors for further investigation.
On the “totality” of evidence from the coronial inquiry, Coroner Caitlin English today said there was the possibility an indictable offence had occurred.
“Ms Day’s death was clearly preventable had she not been arrested and taken into custody,” Ms English said.
Ms Day was in police custody in Castlemaine, after being taken off a Melbourne-bound train in December 2017 to sober up.
She fell and hit her head several times while in the police cell, but her injuries were not discovered for several hours.
On-duty police did not conduct adequate checks of Ms Day, the coroner found.
Ms English questioned the evidence of Leading Senior Constable Danny Wolters, where CCTV footage from the cell contradicted his claims that in his check on her at 5:56pm she was “moving around freely”.
She noted there was a 68-minute gap between the second and third checks of Ms Day, and 81 minutes from the last check to when police opened the cell door after 8:00pm.
She told the court Senior Constable Wolters was not a “credible witness”.
The coroner found Sergeant Edwina Neale and Senior Constable Wolters — who were attending to Ms Day in the cells — showed “cultural complacency” in dealing with people who were intoxicated, using a “minimalised approach to her medical needs”.
They did not take proper care of Ms Day, Ms English said in her findings.
‘Opportunity lost’ for Ms Day to survive after falling
If “proper physical checks had been done every 30 minutes” she would have been checked 10 minutes after the fatal fall in the cell at 4:51pm, Ms English said.
Ms English said “there was an opportunity lost for her survival”.
On December 5, 2017, Ms Day had fallen asleep while travelling by train from Bendigo to Melbourne.
She was taken off the train by V/Line officials at Castlemaine and picked up by police and taken to local police cells to sober up.
A three-week coronial inquest heard last year that during the four hours she was in the holding cell, police officers did not conduct sufficient physical checks on her — as required under police rules.
At the request of Ms Day’s family during the inquest, the coroner released CCTV footage from the cell Ms Day was held in.
It showed her hitting her head at least five times inside the holding cell.
She was eventually taken to Bendigo Hospital, and later to St Vincent’s hospital in Melbourne, where she died 17 days later.
‘Unconscious bias’ a factor in removal from train, coroner finds
Ms Day’s family has pushed for a criminal investigation into the events that day, claiming racism was a factor.
At the beginning of the inquest in August, the family’s lawyer argued Ms Day’s catastrophic injuries had been caused by neglect.
The inquest is the first time special consideration has been given to whether systematic racism was a factor in the way she was treated by authorities, and ultimately her death.
Ms English today said she found evidence from V/Line conductor Shaun Irvine that he did not notice Ms Day’s Aboriginal heritage “unconvincing”, noting his statement made refence to it and also that Mr Irvine mentioned it to police.
She found there was “unconscious bias” by Mr Irvine when he determined Ms Day was unruly and called police.
Ms Day’s Aboriginality was a factor in his response, the coroner said.
Ms Day’s family did not attend the findings hearing because of restrictions at the Coroners Court of Victoria to deal with the coronavirus outbreak.
Before the inquest began the Victorian Government said it would drop the state’s public drunkenness laws, but the changes have not yet been made.
Timeline of Tanya Day’s interactions with police
3:14pm Tanya Day is removed from a V/Line train by police at Castlemaine
3:37pm Ms Day arrives at Castlemaine Police Station
3:56pm She is placed in a holding cell to sober up
4:50pm Ms Day suffers a traumatic head injury when she falls forward and hits her forehead on the wall of the cell
8:03pm Police perform their first physical check on Ms Day — she is on the floor with a bruise on her forehead
8:25pm An ambulance is called
8:54pm Ms Day is taken to Bendigo Hospital in an ambulance with lights and sirens
9.48pm Ms Day is unconscious with bleeding on her brain
3:25am She is flown to St Vincent’s Hospital in Melbourne where she remained unconscious until her death