Aboriginal and Torres Strait Islander viewers are advised that this website contains the names and images of people who have passed
Aboriginal and Torres Strait Islander viewers are advised that this website contains the names and images of people who have passed
34
Police investigations conducted by highly qualified investigators
That police investigations be conducted by officers who are highly qualified as investigators, for instance, by experience in the Criminal Investigation Branch. Such officers should be responsible to one, identified, senior officer.
There are many other examples, like the failure to test the blood found in Mum’s cell, to conduct any investigation into the adequacy of her treatment by paramedics, or to establish what else was happening at Castlemaine police station that night. We don’t believe that the investigation would be conducted this way if anyone other than police officers were implicated…The solution is to have a truly independent investigator for police contact deaths; not police investigating police.
Aboriginal Justice Caucus Assessment
Recommendation 34 intended for police investigations into deaths in custody to be conducted by highly qualified investigators reporting to one, senior officer.
The Victoria Police Manual specifies that the Senior Investigating Officer must hold the rank of inspector or higher within the Homicide Squad and is tasked with leading the investigation. The Homicide Squad comprises skilled and seasoned detectives. Admission to the squad is competitive and reserved for detectives with significant investigative experience.
Past inquests into Aboriginal deaths in custody have highlighted significant deficiencies with police investigations, and critical gaps between policy, as outlined in the Victoria Police Manual, and practice. We know the Victoria Police Manual was updated in 2021 to reflect RCIADIC recommendations and provide specific directions into the conduct of investigations but remain concerned about whether these requirements are met in practice.
If directions aren't followed through, what are the consequences for the lack of investigation or failure to perform their duties like they are meant to be.
(Chris Harrison, Chairperson, AJC)
Recommendation 34 remains relevant until there is an independent body to investigate deaths in custody.
Priority for Further Work:
Moderate
Relevance and potential impact | |||||
|---|---|---|---|---|---|
Low (0-2) | Moderate (3-4) | High (5-6) | |||
Extent of action taken and evidence of outcomes | High (5-6) | ||||
Moderate (3-4) | |||||
Low (0-2) | |||||
Potential Actions for Further Work
Establish an independent coronial investigation unit
Establish an independent investigation unit, and until it is established, create a specialised investigation team within the Coroners Court.
Explore international benchmarking models such as the Police Ombudsman for Northern Ireland to identify best practices for independent investigation units in custodial matters. Evaluate the feasibility of adapting similar models to the Victorian context to enhance investigative integrity and transparency.
Accountability for investigations
Ensure disciplinary action or other consequences for failures to adhere to directives or conduct a thorough investigation. Measures should promote accountability and incentivise compliance with established protocols.
Background
The Royal Commission into Aboriginal Deaths in Custody recognised that police should continue to play a role in investigating deaths that occur in custody and recommended important safeguards to improve the quality and accountability of these investigations. The focus was on making sure investigations are consistent, thorough, and carried out to a high standard. The Commission also supported a more centralised system, with senior oversight and clearer responsibilities, to improve the quality of investigations and ensure that information is collected and reported to coroners in a consistent and reliable way.
Actions Taken Since Last Review
Victoria Police
Victoria Police assessed Recommendation 34 as fully implemented in 2023, noting the current practice is that police investigations of deaths in custody are conducted by the Homicide Squad, with oversight provided by the Professional Standards Command (PSC).
According to Victoria Police, all police investigators within the Homicide Squad are qualified and highly experienced detectives. Entry into the Homicide Squad is highly competitive and is reserved for detectives with extensive investigatory experience.
Impact
Outputs
The Victoria Police Manual outlines roles and responsibilities in relation to the investigation of deaths, serious injury or illness incidents involving police. Requirements for the scope and conduct of the investigation are also included.
Outcomes
Victoria Police confirmed that all deaths in custody are investigated by qualified and highly experienced detectives from the Homicide Squad, with oversight provided by the Professional Standards Command. The Senior Investigating Officer is an officer of the rank of inspector or above from the Homicide Squad. Appointed investigators must follow key principles outlined in police procedures related to crime scenes, and deceased persons.
The investigation team is responsible for conducting a full and detailed inquiry. This goes beyond simply determining if a crime occurred—it must also examine whether the custody was lawful and whether the person received proper care, treatment, and supervision before their death.
Special attention must be given to whether custodial officers followed all relevant policies and procedures regarding the care and supervision of the deceased. In cases involving police watch-houses, investigations must also look into the events leading up to the person being taken into custody, including their arrest and what they were doing beforehand.
Finally, if the investigation reveals that someone committed an offence, it is the responsibility of the Senior Investigating Officer to ensure appropriate legal action is taken.
Past inquests into Aboriginal deaths in custody have highlighted significant deficiencies with police investigations, and critical gaps between policy, as outlined in the VPM, and practice. While the VPM was updated in 2021 to reflect RCIADIC recommendations and provide specific directions into the conduct of investigations, whether these requirements are consistently complied with remains to be seen.
Community Views
Tanya Day's Children
Submission to the Inquest into the Death of Tanya Day
In their submission to the Coroner, Tanya Day's children drew attention to several significant deficiencies in the investigation into their mother's death, including police not following the Coroner’s directions in the investigation. Concerns were raised about the scope, thoroughness and timeliness of the police investigation, as well as its independence:
There are many other examples, like the failure to test the blood found in Mum’s cell, to conduct any investigation into the adequacy of her treatment by paramedics, or to establish what else was happening at Castlemaine police station that night. We don’t believe that the investigation would be conducted this way if anyone other than police officers were implicated…The solution is to have a truly independent investigator for police contact deaths; not police investigating police.
Victorian Aboriginal Legal Service
The Victorian Aboriginal Legal Service (VALS) continues to advocate for measures to improve the quality, conduct and independence of coronial investigations into Aboriginal deaths:
All coronial investigations into the death of an Aboriginal person should be carried out by an independent Aboriginal-led body, on behalf of the coroner. The body should have:
- the powers and training to investigate complaints in a rigorous, timely and effective matter, including the powers to conduct the investigation as a standard criminal investigation and interview police officers, with officers required to co-operate, subject to standard common law rules against self-incrimination
- a statutory basis as an independent statutory body, being properly funded and resourced.
Until an independent Aboriginal-led body is established to carry out coronial investigations, this function should be performed by a specialised Investigation Team at the Coroners Court, that is independent from Victoria Police and any other government authorities:
- The team should be adequately resourced and trained and must include Aboriginal investigators.
- They should work closely with the Koori Engagement Unit when investigating Aboriginal deaths.
- This should be an interim model, to ensure independent and culturally appropriate investigations, while longer-term systemic reform is achieved.