Aboriginal and Torres Strait Islander readers please note that this article mentions deceased persons.
Police officers responding to domestic violence call-outs in the remote central Australian town of Tennant Creek worked off an incomplete flowchart to make bail decisions, a coronial inquest into the deaths of four Aboriginal women killed by their intimate partners has heard.
Three Tennant Creek police officers involved in the case management of one of the deceased women, 34-year-old Kumanjayi Haywood, appeared in Alice Springs Local Court on Friday. They told the coroner their caseload was heavy, training was scarce, and decisions made in relation to domestic violence incidents relied on forms and bail flowcharts that were routinely misunderstood and incorrectly filled out.
“There are likely many, many, many incorrect bail decisions over the last years in relation to breaches of domestic violence orders,” Northern Territory coroner Elisabeth Armitage told the inquest, adding that mistakes are likely not isolated to Tennant Creek given the number of constables that have moved on to other stations and “taken those learnings with them”.
“It’s likely that similar errors are being made across the Northern Territory.”
Both Constable Matthew Murphy and Constable Madaleine Garnsey, as well as Senior Constable (then acting sergeant) Gary Higgie told the inquest that despite experience filling out bail forms, they did not know there were two drop-down boxes relating to breach of domestic violence orders (DVOs) and past criminal history.
“This flowchart is printed off and posted on the wall in Tennant Creek and it was common practice to use this every time we were completing a bail form,” Garnsey told the inquest.
It was understood by officers that the second box titled “Serious Harm: Breach DVO” could only be triggered if someone was charged with both serious harm and had breached DVO. As a result, the decade-long history of serious violence between Kumanjayi Haywood and her partner Kumanjayi Dixon was overlooked.
This included a number of occasions when Dixon was jailed for lengthy periods because of violent assaults (notably an incident in 2017 when Haywood was stabbed 15 times in her leg), a breached DVO in Queensland, repeated breaches of non-contact orders in the six months leading up to Haywood’s death, a serious assault in September 2021 that hospitalised Haywood, and repeated threats to kill her.
There were also a number of other incidents against Haywood that were known to police but not reported, or alternatively reported but not formalised — a statement made one day but not signed the next — and therefore not captured in convicted offences. All of these were logged on the police real-time online management information system (PROMIS). Over 21 years, police recorded 47 incidents between Haywood and Dixon, with 35 confirmed domestic and family violence (DFV) incidents.
Haywood died in November 2021 as a result of injuries sustained in a house fire lit by Dixon, three days after he was granted bail for breaching a domestic violence order.
The bail flowchart forms were first filled out by constables Murphy and Garnsey before being passed on to Higgie to make a final decision. All three landed on a “presumption for” (meaning bail is granted) by drawing on information from the courts (to ensure there were no other live convictions) and what they deemed “relevant criminal history”.
Higgie said that because the November 2021 breach of DVO was “no violence” and there was no evidence of a breached order in the past two years, bail was granted. Had PROMIS history and interstate offences been considered, Higgie acknowledged his decision would have been “against” — meaning bail denied.
Murphy told the inquest that these forms were often done in collaboration with other officers — constables like himself and superiors like Higgie — and no one ever picked up on the errors.
Higgie took responsibility for the oversight, telling the inquest that the constables’ error was his own: “I had a similar train of thought because I essentially gave that guidance to them. And that’s what I was taught from my senior partners.”
“Their oversight was my oversight,” he said.
In a statutory declaration provided to the inquest, he explained that in his capacity as acting sergeant at the time, he relied on the bail flowchart as a “quick guide into whether bail is for or against”.
“The bail flowchart is one of the only tools available to me at the time of making the decision to grant Mr Dixon bail. I had no formal development training with regards to providing higher duties including custody sergeant roles,” Higgie wrote, adding that in his seven-year career leading up to November 2021, he assumed the role of shift supervisor (which in Tennant Creek also performs the duties of custody sergeant) and officer in command a number of times, despite the absence of any training.
Both Murphy and Garnsey also told the inquest about a dearth of domestic violence and cultural awareness training despite domestic violence call-outs accounting for 80-90% of police workload in Tennant Creek. The training they did receive was online and largely related to understanding the domestic violence act. Garnsey said she recalled being shown a “graph” and a “circle” diagram relating to domestic violence.
Murphy, Garnsey and Higgie have all since left the Tennant Creek Station — Murphy to Katherine, and both Garnsey and Higgie to Darwin — and none were given further training or updated advice on how to correctly fill in bail flowchart forms upon arrival.
Murphy told the inquest that he observed no change in bail practice when he moved to Katherine — both stations were operating the same way.
It was not until last month, two and a half years after Ms Haywood’s death, that the officers were notified by Northern Territory police of the administrative error. Murphy told the inquest that he was given no reason from NT police for the delay and confirmed that no changes were made or announced until recently.
The police flowcharts at the centre of all decisions to grant bail have since been reformatted with two separate drop-down arrows, one for “Serious Harm” and another for “Breach DVO”. The new design is to help police ascertain whether an individual has prior guilt for a breached DVO (including in another jurisdiction) or prior guilt for a range of other offences.
The coroner drew attention to the visual resemblance of the old and new flowcharts, particularly in relation to colour choice. She suggested a “whole new set of colours” to ensure officers don’t accidentally pick up the wrong one.
“Someone at every single station is going to have to check that the new flowchart is put up on the wall and the old ones taken down and there aren’t old ones lying around in the bottom of drawers that people are going to pick out,” Northern Territory coroner Elisabeth Armitage said.
The coroner reiterated to all officers that the breakdown in communication and failure to draw on relevant information were indicative of a “general practice” and “widespread approach” in the Northern Territory police, rather than a reflection on the officers and their colleagues. She acknowledged that all of them were young and reliant on their superiors to learn and identify errors in their practice.
All officers expressed deep regret over their errors and extended condolences to the family of Ms Haywood.
If you or someone you know is affected by sexual assault or violence, call 1800RESPECT on 1800 737 732 or visit 1800RESPECT.org.au. In an emergency, call 000.
It is difficult to believe this error could have been so common. In the original format of the flow chart there are two elements in the second box and nothing in that box says whether they both required or just one of them is sufficient. But the first box, the one on its left, is formatted the same way. The elements in that box are also just a simple list. If the second box was interpreted so that all elements were required then obviously the first box must be interpreted the same way. This means that anyone would get bail for any number of the following offences except when they were charged with every one of them, without an exception: Murder AND Terrorism AND Sabotage AND Arson AND Threats to Persons AND Serious Sexual Offence AND Dangerous Drugs AND Customs Drugs Offence AND Cmwth Crim Code Div 30T AND Serious Crimes Control Act.
Was this not a clue on how to interpret the chart? I don’t think it should need Sherlock Holmes to arrive at the right answer. And if that was not enough, why did nobody ask the obvious question about how the chart should be used?
Did the officers have as much time, training and interest in the chart as you have in writing the comment?
You mean, about two minutes to look at it and no training at all? The article says they used it routinely for years and had training. So I guess the answer is they had far more.
Documentation which is widely misunderstood is lousy documentation.
Writing clear concise documentation is too often undervalued until the consequences of the alternative have become apparent.
Not surprised by any of this. In unpopular places like Tennant Creek relatively junior people often find themselves doing higher duties, ready or not. As for training, the further you get from the main centres the harder that is. Plus in a busy station it is hard to even find time for it. Add to that the treatment of on-line learning as merely a box ticking excercise. You dont have to learn anything, just pass the multiple choice test at the end. Supervisors are happy with this because it transfers responsibility to the officer concerned. When the day comes to apply the knowledge it is often under pressure and in situations of high emotion. So mistakes are made. All in all just garbage. No one taking anything seriously.
Then people die.
I am in general on the side of the police. My godson is one and he is a lovely young bloke. However there is a problem with the training and philosophy of our police around the whole nation. It seems to me that they are trained in weaponry and bugger all else. I also think that the selection processes must be awry given some of the dunces we see on public view.(don’t get me started on the Federal version)> We have seen many examples of DV perpetrators in the police and being aided by the police. This must in part be due to a culture that is steeped in the increasingly US concept of punishment at all costs, rather than prevention. THis is how we arrive at the point where women are killed with scant attention paid and elderly women get tasered and killed.
There’s a lot in what you say. The general model being followed these days is more appropriate to deploying an occupation army in hostile territory under conditions of actual or threatened insurgency than the principles put forward for the first modern police force, the London Metropolitan Police, by Sir Robert Peel in the 1829. (However, the current Metropolitan Police has degenerated to the point where its abolition and replacement is probably the best option.) For anyone not familiar, here are those principles:
9 Policing Principles
Just wanted to say I applaud Crikey continuing to support longer-form journalism from Central Australia, now that the politicians have gone back to Canberra and so too the national media. There is no local news outlets here; just the ABC (which finds itself hopelessly conflicted sometimes) and so-called social media (enough said).