Inquest into the death of Valerie Wurramurra [2004] NTMC 091

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CITATION: Inquest into the death of Valerie Wurramurra [2004] NTMC 091

TITLE OF COURT: Coroner’s Court


FILE NO(s): D0068/2002

DELIVERED ON: 20 December 2004


HEARING DATE(s): 1, 2 June, 19 August, 24 September 2004

FINDING OF: Mr G Cavanagh SM

Unexpected death, uncertain and suspicious circumstances concerning death, quality of police response, open finding


Assisting: Mr John Lawrence
Aboriginal Justice Advisory Commission Mr Chris Howse
Northern Territory Police Force Mr Steve Southwood QC

Judgment category classification: B
Judgement ID number: [2004] NTMC 091
Number of paragraphs: 46
Number of pages: 19


No. D0068/2002
In the matter of an Inquest into the death of

ON 13 APRIL 2002


(Delivered 20 December 2004)

1. Valerie Wurramara (“the deceased”) died at approximately 10:30pm on 13 April 2002. She died at sea somewhere between Alyangula on Groote Eylandt and Bickerton Island. For reasons which will appear below in these findings, the death was one which was unnatural and appeared to have resulted from an accident or injury and as such was a reportable death within the meaning of section 12(1) of the Coroners Act (“the Act”). Pursuant to my discretion under section 15(2) of the Act I held a public inquest into the death of the deceased.
2. The inquest was held on 1 and 2 June 2004 at Alyangula and 19 August and 24 September 2004 in Darwin. At the hearing on 1 June, leave was granted to Mr Howse from the Aboriginal Justice Advisory Commission to appear, and on 18 August leave was granted to Mr Southwood QC to appear for the Northern Territory Police Force. Counsel assisting me was Mr Lawrence.
3. The inquest heard sworn evidence from six Aboriginal witnesses who were friends or relatives of the deceased and were with her earlier on the day that she died: Allan Wurramara, Samara Wurramara, Elizabeth Mamarika, Tony Bara, Holly Yantarrnga and Tally Mamarika. Statements from other witnesses were admitted into evidence as part of Exhibit 3. The inquest also heard from four police officers: Sergeant Foley who was responsible for overseeing the second coronial investigation, S/Sgt Hollamby, the OIC of Alyangula police station at the time of the death, Constable Ramage, who was the OIC of the original police and coronial investigation, and Constable De Nale who dealt the deceased earlier on the day of her death. Forensic Pathologist Emeritus Professor Green also gave evidence on 1 June via phone link from Leeds, UK.
4. Section 34 of the Act sets out the matters that the coroner is required to find during the course of an inquest. That section provides:
“(1) A coroner investigating –
a) death shall, if possible, find –
(i) the identity of the deceased person;
(ii) the time and place of death;
(iii) the cause of death;
(iv) the particulars needed to register the death under the Births, Deaths and Marriages Registration Act;
(v) any relevant circumstances concerning the death.
(2) A coroner may comment on a matter, including public health or safety or the administration of justice, connected with the death or disaster being investigated.
(3) A coroner shall not, in an investigation, include in a finding or comment a statement that a person is or may be guilty of an offence.
(4) A coroner shall ensure that the particulars referred to in subsection (1)(a)(iv) are provided to the Registrar, within the meaning of the Births, Deaths and Marriages Registration Act.
5. Furthermore Section 35 states:
“(1) A coroner may report to the Attorney-General on a death or disaster investigated by the coroner.
(2) A coroner may make recommendations to the Attorney-General on a matter, including public health or safety or the administration of justice connected with a death or disaster investigated by the coroner.
(3) A coroner shall report to the Commissioner of police and the Director of Public Prosecutions appointed under the Director of Public Prosecutions Act if the coroner believes that a crime may have been committed in connection with a death or disaster investigated by the coroner.”
Coroner’s Formal Findings
6. The formal findings I make in this matter are as follows.
(a) The identity of the deceased is Valerie Wurramurra, an Aboriginal woman living at Bickerton Island at the time of her death, and born on 9 March 1966 at Angurugu, Groote Island in the Northern Territory of Australia.
(b) The time and place of death was approximately 10:30pm on Saturday 13 April 2002 at sea somewhere between Alyangula and Bickerton Island in the Northern Territory of Australia.
(c) The cause of death was drowning caused by self-inhalation of vomit.
(d) The particulars required to register the death are:
1. The deceased was a female.
2. The deceased was an Aboriginal Australian.
3. A postmortem examination was carried out and the cause of death was as per (c) above.
4. The pathologist viewing the body after death was Dr Michael Green, locum forensic pathologist of the Royal Darwin Hospital who carried out the post-mortem examination.
5. The mother of the deceased was Jamani Dungwangidja Lalara and the father of the deceased was Andrew Jubanigaga Wurramara.
6. The deceased resided at Bickerton Island in the Northern Territory.
7. The deceased was unemployed.
Events leading up to and immediately after the death
7. The deceased was born in 1966 on Groote Eylandt at Angurugu. She was 36 years of age at the time of her death. She had been married in the traditional Aboriginal way to Mr Andrew Yantarrnga. They resided on Bickerton Island, being Wurramara county, an island 25 km northwest of Groote Eylandt.
8. On the day that she died, at around lunchtime, the deceased, her husband about six other people came over to Alyangula. The deceased and her husband travelled in Andrew Yantarrnga’s 4 1/2 foot aluminium dinghy powered by a 40 hp engine.
9. At Alyangula the boat landed near the boat ramp which is beside the public swimming pool, and a group of people from Alyangula met up with the arrivals from Bickerton. Some of the people including the deceased’s husband were drinking alcohol. At some stage an argument occurred between the deceased and her husband over the question of returning to Bickerton Island. According to Elizabeth Mamarika, the deceased was crying. When asked why she was crying, she “told [Elizabeth] that Andrew had punched her once”.
10. There is evidence of Andrew Yantarrnga’s father, Wanella Yantarrnga, telling Andrew to stop “talking silly” to his wife.
11. At about 3pm that afternoon First class Constable De Nale responded to a report from the Alyangula Recreation Club that a person was purchasing alcohol for sale to the Aboriginal people who had come over from Bickerton Island. Constable De Nale proceeded to investigate this possible breach of the Liquor Act and ultimately arrived, alone in his caged police vehicle at the boat ramp. As he arrived, Andrew Yantarrnga and another man “sped off” in the dinghy. The deceased and Elizabeth Mamarika approached him and the deceased got into the back seat of the twin cab police vehicle and asked to be driven to Angurugu. She told Constable De Nale that she had been hit by her husband and she was scared. Constable De Nale told her he would not drive her to Angurugu but would take her to a relatives home in Alyungula. The place that she nominated was Joaz Wurrumurra’s home, approximately 400 metres away.
12. His reason given in evidence (not to the deceased) for declining to drive her to Angurugu was that she was a woman, he was a man working alone and it was 18 miles away. During the drive there was a conversation between Constable De Nale and the deceased about her alleged fears and about her options in terms of making a complaint. According to the officer, the deceased retracted her initial assertion that her husband had hit her and said that they were just “arguing” about her not wishing to return to Bickerton Island, and she did not wish to make a complaint but simply be away from him for one night. When he dropped her off, he said she appeared “fine”.
13. Constable De Nale made an entry on PROMIS later that day detailing his investigation of the potential breach of the Liquor Act at the boat ramp. He made no mention of any domestic violence complaint. He did mention the deceased by name in the context of her apparently indicating to him that if there was any alcohol it had gone on the boat which had sped off. I return to these dealings between Constable De Nale and the deceased later in my findings.
14. The deceased remained at Joaz Wurramara’s house at least into the late afternoon when she went to her sister’s house. Andrew Yantarrnga returned at some stage to his father’s house in Angurugu. He, along with Johnny Mamarika and Mr Wanella Yantarrnga, telephoned the police station to ask Constable De Nale to bring the deceased out to Angurugu. Constable De Nale told them that she was spending the night with family in Alyangula, she was safe, and he would not bring her to them.
15. It is unclear on the evidence precisely how, but the deceased and her husband met up again around mid evening at Alyangula, and reboarded the dinghy with the apparent intention of travelling to Bickerton Island. At around 10:30pm Andrew Yantarrnga knocked on the back door of the Alyangula police station where he was met by Constable Ramage. I quote from the statutory declaration of Constable Ramage (Ex 3 Folio 28):
I said “What can I do for you?”
He said “I was going back to Bickerton Island with my wife because we’d had that argument and when we got near Connexion Island she went to the front of the boat and jumped out and hit some rocks”
I said “What’s your name and what’s your wife’s name?”
He said “My name’s Andrew Y and my wife’s was Valerie Wurramara”
I said “Where is Valerie just now Andrew?
He said “She’s in the boat down that boat ramp”
I said “Is she alive?”
He said “No, I think she’s finished up”.
16. Constables Ramage and Marsh went with Andrew Yantarrnga down to the boat ramp and observed the deceased on the floor of the dinghy dead. She had obvious head injuries. Dr Marion Evans from Alyangula Health Centre was called out and made observations and pronounced death at 10:52am Saturday 13 April 2002. Photographs taken of the deceased and the dinghy form part of Exhibit 3. While still at the boat ramp Constable Marsh asked Andrew Yantarrnga what happened, and he told him that the deceased was standing up at the front of the boat, that he hit something in the dark, and “she fell out the front”.
17. Arrangements were made by the police to take the deceased’s body to the morgue at Alyangula Health Clinic. At 1:15am on 14 April 2002 the body of the deceased was identified by Mr Joaz Wurramurra. Mr Yantarrnga went back to the police station and remained there overnight at his own request (for fear of customary punishment).
18. The OIC at Alyangula, Senior Sergeant Hollamby (now Superintendent), assumed control of the investigation. He made a telephone call to Divisional Superintendent O’Meara, and in consultation with the Superintendent, decided that the police investigation would be conducted locally without calling out a CIB unit from Darwin. S/Sergeant Hollamby delegated the investigation to Constable Ramage, a junior uniformed officer of three years experience who had never conducted a homicide investigation.
19. It was discovered very early on in the police investigation that the deceased and Andrew Yantarrnga had a relationship which involved instances of him assaulting her. In fact in January 2002 he was charged with aggravated assault over an allegation that he had assaulted the deceased with a stick at Angurugu. During a formal interview with police he admitted hitting her, and he was charged and bailed. He failed to appear in court in relation to that charge and a warrant was issued for his arrest, which was still current at the time of these events.
20. Superintendent Hollamby maintained under cross examination that the information about the history of domestic violence between Yantarrnga and his wife, some of which he became aware of early on the Sunday morning, did not affect his assessment that the death was “unusual” rather than “suspicious”. In addition he said that he wanted to wait for the results of the autopsy to determine whether there were suspicious aspects to the deceased’s injuries which warranted a criminal investigation.
21. Consequently, it was Constables Ramage and Marsh who took a recorded statement from Andrew Yantarrnga at 10am Sunday. Prior to the interview Constable Ramage was instructed by Superintendent Hollamby not to caution Andrew Yantarrnga as a suspect but to take a taped witness interview statement. In that interview Mr Yantarrnga first said this about what occurred (p10):
“And I left this Alyangula part a bit dark and went to the side of this island Connexion island and I went close and my wife she was sitting together and my wife she went to the front of the boat in the front and from there my wife she stand up, stood up and she slipped in the water. I must stop the motor and I come up from the boat looking for her and I found her and collect my wife back to the boat”.
22. His version became somewhat more confused upon continued questioning. I quote from page 15 where Constable Ramage makes reference to his earlier conversation with Andrew Yantarrnga which took place at the back door of the police station:
“Q. You told [me] that your wife had jumped out of the boat. Now, did she jump did she jump?
A. She jumped on the front and she slipped over.
Q Mm so she was actually standing on that, that covered aluminium part of, on the top of the very front of the boat?
A. Yeah, I don’t know what got into her.
Q. Did you think it was a deliberate jump or did she slip?
A. Ah no, slip
Q. Well what did it look like? Did it look like she slipped or did it look like she jumped?
A. When you people like you know
Q She dived in head first
A. Yeah
23. During the interview, which went for approximately one hour, he was asked several times how his wife left the boat, and in the main he said that she slipped. Questions about whether Mr Yantarrnga may have run over the deceased with the boat also met with unclear answers. Of some significance in terms of assessing his explanation, is that fact that Mr Yantarrnga was not truthful about the domestic violence history between himself and his wife, including the most recent incident giving rise to the outstanding charge of aggravated assault.
24. Unfortunately there has been no further opportunity to interview Mr Yantarrnga nor have him give evidence to this inquest. Some time in the May after his wife’s death, Mr Yantarrnga was hit from behind by a relative with a shovel causing a very serious head injury. He was in the intensive care unit at the Royal Darwin Hospital for 72 hours and remained at hospital for about seven weeks. Constable Ramage sought to interview him again at some time after April but discovered through family and friends that due to his injuries, he was not able to give any credible account of the events of 13 April 2002. Attempts were made again in September 2003 which were recorded and transcribed and again Mr Yantarrnga was unable to give any recall of the events. He was not called as a witness after counsel assisting the inquest personally interviewed him prior to the inquest commencing on 1 June and determined that it would not be appropriate. I note that Mr Yantarrnga spent much of the two days at Alyangula, sitting in court; I observed a very large dent in his head and he appeared listless and vague.
25. Constable Ramage’s investigation also included removing the engine propellor from the boat and sending it to Darwin to query with the pathologist whether the injuries to the deceased were consistent with being caused by the propellor. Professor Michael Green, the consulting forensic pathologist who performed the autopsy, gave his opinion in evidence that the injuries were consistent with being caused by being run over by the propellor. Further there were no other injuries which definitely pointed towards an assault. Fractured ribs could have been caused by Mr Yantarrgna’s attempts at CPR and the absence of overlying bruising was consistent with this mechanism of injury.
26. Most of the statements taken from the Aboriginal witnesses were also taken in the first few days of the incident. Superintendent Hollamby left his posting in Alyangula three weeks after the incident which is relevant in explaining why his statement didn’t go in until one year later.
27. Constable Ramage’s investigation was completed on 8 December 2002 and forwarded through formal police channels but was not considered adequate by senior officers. In early 2003 Detective Sergeant Foley received the investigation brief and was tasked to overview it. She completed her investigation in September 2003. The delay in finalising the whole investigation is to be deprecated.
28. In terms of making a finding as to the medical or immediate cause of death I am satisfied with the evidence of Professor Green as to how that occurred. The difficulty comes with determining what occurred during the moments immediately prior to the deceased ending up in the water, being injured by the propellor and drowning. As was recognised by Detective Sergeant Foley when she commenced her review, the first investigation did not reach a clear or satisfactory conclusion as to the manner of the deceased’s death – did she slip, did she jump, and if so what caused her to do either?
29. Andrew Yantarrnga took the police to the place where he said the deceased fell into the water. Constable Ramage subsequently took statements from two witnesses who were fishing from the wharf on the night in question and saw Mr Yantarrnga return in the dinghy with the deceased. Their version as to the direction in which the dinghy arrived were different from the version given by Mr Yantarrnga on 14 April. By the time Constable Ramage sought to re-interview Mr Yantarrnga on this point, he had already sustained the injury which rendered him unable to recall the events then or now. An immediate and thorough interrogation of Andrew Yantarrnga by an experienced CIB officer on the day after the death may have led to a clearer result.
The decision not to call out CIB
30. The decision made by Superintendent Hollamby not to call out CIB was the subject of extensive cross-examination and submissions in this inquest. Superintendent Hollamby frankly and readily conceded in evidence that if he had his time over he would certainly call out CIB immediately. His concession was somewhat undermined, however, by his assertion that his assessment of the incident at the time as ‘unusual’ but not suspicious was still appropriate, even in hindsight.
31. The discovery of Constable De Nale’s involvement with the deceased the day of her death was something which should not only have increased suspicion in terms of the proximity between her complaint and her death, but also gave rise to the potential for criticism of the way in which he had handled the situation. Although he claims no specific recollection, Superintendent Hollamby must have been aware of the potential significance of those dealings, to the point that inquries were made (on the night of the death and afterwards) of my office as to whether the death should be classed as a death in custody. (On this point there is no dispute that as the deceased was never in police custody, it did not fall within that definition under the Coroners Act.)
32. Superintendent Hollamby firmly denied that his decision not to call in CIB was based upon a desire to protect his officer De Nale from criticism in relation to his dealings with the deceased the day before and I accept that denial. However, the circumstances of one of his officers having failed to respond to a complaint by the deceased of fear of her husband on the very day of her death when alone with her husband, should have alerted a prudent senior officer to the dangers of having the investigation conducted “inhouse”. I have already noted my view that the investigation would have been more timely, and more than likely more effective had CIB conducted it.
Constable De Nale’s involvement with the deceased
33. The Police General Orders relevant in this particular situation come from D7 which address domestic violence situations and in particular, situations involving traditional aboriginal women. I set out here some of the relevant orders about which Constable De Nale was questioned:
“1.5 Where a complaint of physical violence, threats of violence, intimidation or harassment of any person within a domestic/family environment is received, the complaint is to be treated as a serious crime. It is inappropriate that mediation be used as a substitute for appropriate criminal proceedings.
4. Minimum Response
4.3 Where an order is not obtained, members will be required to record on PROMIS comprehensive reasons as to why no action was taken.
4.4 There are five recognisably different domestic violence situations requiring different minimum responses for each.
4.4.1 The five different situations are those where the alleged offender has or may have:
1. breached a restraining order obtained under the Domestic Violence Act
2. committed an assault
3. engaged in threatening, offensive or provocative behaviour;
4. caused damage to property; or
5. entered into a verbal argument
4.6.5 Verbal argument
Members are advised to:
1. provide initial advice and a DV contact card and explain relevant legislation and options available, eg Orders;
2. update all details on PROMIS including ‘confirmed incident type’ indicating action taken and reasons for taking action; and
3. implement Section 4 restraining order where appropriate, or update PROMIS and give reasons why not implemented.
7. Advising victims of their options
7.3 Notwithstanding previous instructions, in some cases victims will insist that no order is taken out, and no amount of encouragement will change their minds. Generally, members should respect their right to make that choice. However, in a situation where it is obvious that any victim:
• is not able to make a rational decision because he/she is traumatised, injured, or too afraid of the offender, and/or
• because of his/her lack of sophistication or language difficulties cannot understand what can be done under the legislation,
then it may be appropriate to apply for an order on the victim’s behalf, whether or not he/she consents.
18 Violence against Aboriginal Women
18.2 Some Aboriginal women, particularly those from remote communities, have great difficulty in reporting incidents of violence and pursuing an application or prosecution because of cultural factors such as family obligations and responsibilities. Fear and shame may be dominant influences upon their decision to report or pursue a matter.
18.3 Members should be aware that the issue of violence against Aboriginal women is a particularly sensitive and complex matter. Members must ensure that the most appropriate action is taken in each set of circumstances, having due regard to the cultural context and the special interests of female Aboriginal victims.

34. The day after the deceased’s death, Sunday 14 April 2002, Constable De Nale made a statutory declaration. He made another in about July 2003 during the reviewing investigation by Detective Sergeant Foley. Both statements were adopted by him in this court. On Sunday 14 April, and again in his statutory declaration made in July 2003, he described his decision not to take any action in relation to the deceased’s complaint this way:
“I observed no injuries to VW and she later advised me that she had not been hit by her husband, but was scared that he would hit her. I dropped her off outside the front of Joaz’s residence and saw Joaz walk out on his front verandah as the police vehicle pulled up in his driveway”.
35. At the time Constable De Nale made his first statement, on 14 April 2002, he knew that the deceased had died when alone with her husband and that his dealings with her the day before might be the subject of criticism. I note this because it is to be assumed that he would take particular care to clarify what had occurred and in particular why he had determined to take no action in response to the deceased’s complaint.
36. The officer was asked on a number of occasions when giving evidence in this court, why he did not place an entry on the PROMIS system recording his decision to take no action in relation to the deceased’s complaint, as is required by Order D7, when he made the entry about the Liquor Act breach. He said (transcript 19/8/04 page 24):
Q. What I’m asking you is, you had the opportunity having made this entry into the computer system to put in an explanation consistent with general orders why there was no follow up in relation to the situation that met you with the deceased that afternoon?
A. I’m not 100% sure how I’m going to answer this question, but I’ll do my best. The reason why I haven’t entered an entry on there relating to domestic violence is because I do not feel at the time after my speaking to her, I did not feel it was a domestic violence incident. It was a domestic violence – it was a domestic disagreement where I conveyed somebody from one place to another. During that time that I conveyed her she indicated to me that the initial report that she had said to me in order to get her – get her into the vehicle, okay, was not what she initially reported. And as soon as she said she wasn’t assaulted, I asked her, “well what happened?” okay. She gave me indications of what happened and through further questioning in the vehicle as I’m conveying her to Joaz’s house she’s indicated to me that it was nothing more than her husband wanting her to go to Bickerton Island and her not wanting to go. So she was just getting away from him so she wouldn’t have to go to Bickerton. So as far as I was concerned it was a straight conveyance from the beach to Joaz’s house after making all those inquiries. So its turned out from being something to a non-domestic violence incident to a straight conveyance.
37. I assess the actions of Constable De Nale on the day in question in isolation from the subsequent events, and from the other information which he did not have about the domestic violence history between the deceased and her husband, because he was not aware of them. Constable De Nale conceded that the conversation he had with the deceased was in fact a question and answer type conversation to which she mainly contributed “yes” and “no”. Although he observed no injuries on her, she was of course fully clothed, and sitting in the back seat of the twin cab during the 400 metre drive. The officer was reluctant to agree with the proposition put to him in cross-examination, that it was an unusual thing for a traditional Aboriginal woman to seek out the assistance of police to the point of getting into a police car in front of her husband and others.
38. A further difficulty lies in his evidence of his firm conclusion at the time he left her that she had in effect withdrawn her earlier complaint, and simply wished to be away from her husband because she did not want to go to Bickerton Island. Constable De Nale said in evidence that by the time he dropped the deceased off at Joaz Wurramurra’s house he had formed the view that she was ‘fine’, and she showed no signs of being scared. By contrast in his statement of 14 April he said as previously quoted “she later advised me that she had not been hit by her husband, but was scared that he would hit her”. He did not say that she had said to him, or he was otherwise satisfied, at the time he dropped her off, that she no longer held fears. In my view his earlier statement, made the next day, and in circumstances where he knew it was important, is likely to be the more accurate.
39. The situation did not improve when Constable De Nale received the telephone call from Andrew Yantarrnga and Johnny Mamarika asking for the deceased to be brought to them in Angurugu. Andrew Yantarrnga’s father, in his statement made 14 April 2004 said that Andrew phoned the police about 5pm and “after he finished talking he gave the phone to me and I talked to Angelo [De Nale] and he told me that Andrew’s wife was upset and that’s why she went to the police so Andrew should stay away from his wife tonight”. This is consistent with Constable De Nale’s statutory declaration of 14 April in which he says he spoke to each of Johnny Mamarika, Andrew Yantarrnga and finally Wanella Yantarrnga (Andrew’s father) and told them that the deceased wished to stay away from Andrew until tomorrow. In his own words, he “warned all three that she wanted to stay away from Andrew until the following day”. This warning was in the context of leaving the deceased at Joaz’s house on the basis that although he had not hit her, the deceased was scared that her husband would hit her. It did not prompt Constable De Nale to make any further inquiries nor any notation on PROMIS.
40. Constable De Nale repeatedly asserted that because he had formed the view that the situation was not one of domestic violence, but simply a “domestic disagreement”, he was not required to comply with General Order D7. I found this answer to be an unsatisfactory attempt to explain his actions. If it be true, it circumvents the spirit and intent of that general order. It is clear from the text of the order that police are to take allegations of domestic violence seriously, are to assist the victims including in some cases to take orders out on the victim’s behalf without consent, and are to take into account the special situation of traditional Aboriginal women. I find that the situation when he dropped the deceased off was as he stated in his statutory declaration of 14 April rather than as he now describes it – that is, that the deceased had told him she wished to take no action but wanted to be away from her husband because she was scared he would hit her. In those circumstances, further scrutiny was required. If upon further scrutiny, no action was warranted, then at the very minimum an entry to that effect should have been made on PROMIS. The requirement to update PROMIS even if an order is not taken out with comprehensive reasons why no action was taken is there for obvious reasons. I find that Constable De Nale failed to comply with it as he was required to do.
41. The consequences of this failure are somewhat speculative. If he had complied with D7 it may have been discovered that there was an arrest warrant out for Andrew Yantarrnga regarding assaulting the deceased in January, as well as the domestic violence history. Those things may have prompted the police to seek to speak to the deceased again, or may have raised police concerns when the phone call came in the early evening from Mr Yantarrnga and others looking for her. It was the police evidence that the general policy on Groote Eylandt was not to go out and execute arrest warrants but merely wait until the subjects find themselves in police presence. If this is a general policy it is somewhat concerning. However, in these particular circumstances I accept as reasonable Constable De Nale’s evidence that he would not have attempted to execute the warrant for Andrew Yantarrnga that evening in any event as he was on duty alone. I accept the submission of Mr Southwood QC that taking the circumstances as a whole it cannot be said that the failure to make an entry on PROMIS as required by General Order D7 contributed to the death of the deceased.
42. As adverted to above, it may have been the case that the involvement of an experienced CIB detective from the outset of the investigation would have provided some clearer answers as to how the deceased met her death. Certainly it would have resulted in a more thorough and timely investigation from the outset which would have reduced the distress of the grieving family and community.
43. Taking into account that some of Mr Yantarrnga’s answers to Constables Ramage and Marsh about his history were not true, and the fact that he gave more than one version of how his wife left the boat, I am not able to accept his version of what occurred. Equally, I cannot find evidence that he had any deliberate involvement in the death of his wife.
44. It is most unsatisfactory, but I must ultimately reach an open finding as to how the deceased met her death.
45. I may have been minded to recommend that the Commissioner review Police General Orders in relation to the investigation of suspicious deaths, however, I note that a (proactive) review has already been carried out. It is now a requirement that the Major and Organised Crime Division are notified of all sudden and suspicious deaths to ensure that an appropriate level of investigative experience is applied to the initial assessment and subsequent investigation into the circumstances of the death.
46. I recommend that Constable De Nale be counselled in relation to the circumstances of this incident and his responsibilities pursuant to General Order D7 relating to domestic violence situations. The Commissioner may consider an application of the facts of this matter to a case study for use at the Police Fire and Emergency Services Training College when training police recruits in relation to domestic violence responsibilities.

Dated this 20th day of December 2004.