Coroner's Act In the matter of Coroner's Findings and Recommendations into the death of Kunmanara Forbes pursuant to section 46B dated 2 December 2009
Tabled paper 660
Tabled papers for 11th Assembly 2008 - 2012; Tabled papers; ParliamentNT
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workers, clinic workers etc. He submitted a file to his supervisor in Alice Springs approximately one year after the death, but the file was not deemed completed to a suitable standard at that time. 49. The location of the file (from a police administrative point of view) is unclear during the next several months but at one stage it was recorded on the PROMIS system as being with the Coronial Investigation Unit. A/Commissioner McAdie appropriately conceded that one of the major contributors to the delay in completion of this file was a lack of clarity, at times about who was in charge of the file and who was responsible for its timely completion (Transcript pi34). In May 2008, Detective Butcher was temporarily transferred from Investigations Alice Springs to Yulara, to relieve as the Officer in Charge at Yulara (the previous officer in charge referred to, having by then taken long service leave). She was allocated the coronial investigation file as one of her tasks. She commenced the investigations while in Yulara and continued them upon her return to Alice Springs in' about September 2008. Detective Butcher first submitted the file to her supervisor, Senior Sergeant Lauren Hill in November 2008. The file was returned to her, with S/Sgt Hill directing some further investigations to be carried out. The file was again submitted by Detective Butcher in early January 2009 and was delivered to my Office by S/Sgt Hill at the end of that same month. The coronial brief ultimately received was of a high standard. My counsel-assisting, Ms Roberts, has received all of the assistance and cooperation she has requested from both officers in preparation for the inquest. 50. Detective Butcher agreed in evidence that there were forensic disadvantages arising from having to commence an investigation some 18 months after the death had occurred and Assistant Commissioner McAdie also appropriately agreed that there are obvious problems associated with such a delay. He did not seek to assign blame to any particular individual but acknowledged that the responsibility lies with police management. 19
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