Queensland police officers were not provided with adequate information when tasked with guarding a violent criminal who was shot dead at Ipswich Hospital, Queensland's state coroner has found.
Tyson Jessen was fatally shot by an officer while under police guard at Ipswich Hospital in November 2018.
Jessen was wanted by Victoria Police over an armed robbery and had been arrested on an extradition warrant before being taken to hospital after suffering a medical episode.
During an inquest held in Brisbane last year, the court heard Jessen had been under round-the-clock police guard and had initially been handcuffed to his bed, but at some point the restraint was removed and not refitted.
The coronial inquest into his death, held in the Queensland Coroner's Court, heard Senior Constable Leesa Richardson and her partner Constable Isaac Collihole had taken over watching Jessen on the day of his death, and that during the evening she had been left alone with him.
It was during this time Jessen attacked Senior Constable Richardson, attempting to take her gun before she shot him three times, fatally wounding him.
The inquest heard that before taking over guard duties, Senior Constable Richardson and her partner had not been told Jessen was a dangerous and high-risk prisoner during their handover, and had not been briefed on the extent of his violent history.
However, the court heard this information was available to all officers on the Queensland Police Service's (QPS) QPrime system — an internal database with offenders' criminal history.
When handing down his findings into Jessen's death, State Coroner Terry Ryan accepted that the officers had relied on verbal briefings in the absence of watchhouse paperwork, as other systems were not in place.
Officers failed to adhere to 'good policing practice'
However, the coroner found the pair made poor decisions, which included Senior Constable Richardson discussing meal break arrangements in front of the prisoner, allowing her partner to leave the ward without completing a risk assessment and failing to reapply handcuffs.
"Senior Constable Richardson and Constable Collihole did not appropriately manage the risks associated with guarding Jessen and did not adhere to good policing practice in maintaining situational awareness," Coroner Ryan said.
Despite this, Coroner Ryan acknowledged Senior Constable Richardson's bravery and recommended she be recognised for her actions.
He also found more information should have been provided about Jessen's history, but said "individual officers also needed to be disciplined in checking QPrime in order to appropriately complete a risk assessment".
It was noted that this information may have made a difference to the officers' approach in guarding Jessen.
Coroner Ryan said the reliance on verbal briefings allowed for information to become "distorted", which showed the need for "contemporaneous reliable documentation in QPrime" for all officers to access and check before guarding a prisoner.
Coroner recommends police manual be reviewed, improved communication
Handing down his findings, Coroner Ryan recommended QPS should consult with Queensland Health to ensure a "consistent approach" in the development of security staff in hospitals and health services when managing patients in police custody.
He said better use of technology was needed to "reduce the need for medical transfers of persons in police detention watchhouses".
He questioned whether other measures adopted by West Moreton Health could be applied in other hospitals and health services.
Coroner Ryan also recommended Queensland police review its Operational Procedures Manual to consider whether it should include an order that risk assessments be completed, and relevant information recorded in both the manual and in an offender's QPrime cautions.
Coroner Ryan said he was "satisfied West Moreton Health has implemented appropriate measures … to attempt to avert this type of incident from occurring again".
It comes after the hospital implemented a policy and made a series of improvements to protocols following the incident.
