A pre-inquest conference into the death in custody of two Indigenous women in Queensland has heard that physical checks by watch house staff may not have complied with adequate police procedures on both occasions.
On Thursday, the revelations emerged at the Brisbane Coroners Court where the cause of Sherry Fisher-Tilberoo and Vlasta Wylucki’s deaths was revealed.
Both women died from natural causes while being held on remand in the Brisbane City and Southport Watch Houses respectively.
Thursday’s conference was to determine whether the matters should jointly be heard together.
Family members and supporters of the two women packed the court.
Counsel assisting the coroner, Alana Martens, said a joint inquest would allow “systematic issues” into the management of prisoners in police watch houses to be addressed, along with the individual circumstances of each of the women’s deaths.
“The information available to date suggests at the very least the adequacy of the physical checks being conducted on these women prior to their death may not have complied with OPMs (operational procedures manual),” said Ms Martens.
“There may be systematic issues with respect to the management of prisoners in watch houses.”
A date has not been set for the inquest but Deputy State Coroner Jane Bentley indicated another pre-inquest conference would be required.
Ms Fisher-Tilberoo, known to the Brisbane Indigenous community as “Aunty Sherry”, died while being held on remand in the Brisbane City Watch House in September this year.
Ms Martens said Ms Fisher-Tilberoo was regularly inspected while in the watch house.
However, at about 6.20 am on September 10, Ms Fisher-Tilberoo was observed by staff to not be breathing and was declared dead 10 minutes later.
Her cause of death was “a subarachnoid haemorrhage due to a ruptured berry aneurysm”.
Ms Martens said the preliminary view of investigators examining Ms Fisher-Tilberoo’s death was that there were “deficiencies in some of the physical checks” which did not meet police procedure requirements.
Ms Wylucki died in March 2018 while being held in the Southport Watch House.
Ms Martens said Ms Wylucki was in “good spirits” and told police she had a heart condition when asked of any medical conditions.
Her medications were handed into the watch house staff when she was arrested.
“There’s no record in the custody report that indicates when these medications were required to be taken,” Ms Martens told the court.
Ms Martens said 11 of the 13 checks on Ms Wylucki may not have been conducted to a satisfactory standard.
Ms Wylucki was found unresponsive in her cell at 6.02am on March 1, 2018.
“(Her) cause of death was ischaemic heart disease due to, or as a consequence of, coronary atherosclerosis,” Ms Martens said.
Both women‘s inquests are expected to examine their cause of death; the adequacy of checks conducted by watch house staff while they were in custody; the adequacy of medical treatment provided; and the appropriateness of “current Queensland Police Service policies and procedures relating to the supervision of prisoners in watch houses”.
Ms Fisher-Tilberoo’s inquest is also expected to consider the appropriateness of the communication with the family and next of kin following her death.
Ms Bentley adjourned the inquest to a date to be fixed and said a further pre-inquest conference may be required when more material becomes available.
Outside court, Ms Fisher-Tilberoo’s nephew, Troy “Juganji” Brady said the family just wanted to get to the truth of their beloved aunty’s death.
“We want to find out exactly what went wrong,” said Mr Brady.
“She was special to us, she was somebody.”