Coroner has commenced proceedings. Will be posting in this thread.

#JusticeForTanyaDay #RememberHerName #EndAboriginalDeathsInCustody #BlackLivesMatter #AboriginalLivesMatter

Coroner’s role is to identify causal factors and systemic failures leading to deaths and contributing to reduction in number of preventable deaths. Coroner doesn’t make determination of guilt or evidence, but is obliged to notify DPP of indictable offences. #JusticeForTanyaDay

Coroner now re-hashing RCIADIC. 339 recommendations made.
Ms Day was the second member of her family to die in custody after her cousin Harrison Day (1982).
Relevant RCIADIC recs: decrim public drunkenness, standards of coronial inquest, policing practices.
#JusticeForTanyaDay

RCIADIC made recs re: shortcomings of investigations into Aboriginal DIC. #12 provides coroner inquiring into DIC be required by law to look into not just circumstances of death but care, treatment and supervision of person prior to death. Coroner deems this relevant.

Coroner has considered preventabliity of Ms Day’s death in accordance with entirety of circumstances on the day in question. #JusticeForTanyaDay

Inquest assessed relevance of systemic racism in the death of Ms Day. RCIADIC defined systemic racism in relation to carceral system’s engagement with Aboriginal people. Relevant here: q of public drunkenness and unconscious bias in decision-making. #JusticeForTanyaDay

Cross-examination attempted to determine whether Metro, VicPol or Ambulance engaged in unconscious bias. All denied this. Coroner rejected use of inductive reasoning in her ruling saying that statistical evidence has no bearing... #JusticeForTanyaDay

Forms of evidence provided: written statements and oral evidence from witnesses; real-time evidence (CCTV footage); org policies and training materials; circumstantial evidence- inferences used to reconstruct event not actually witnessed. #JusticeForTanyaDay

Coroner discussing reasonableness of inferences. Quoting prior judgement- Seldom is there the case where there is admission of racism or direct evidence, so inferences required to draw conclusions. #JusticeForTanyaDay

Application of charter of human rights and responsibilities relevant here. Scope of inquest has considered possible systemic causes of Ms Day’s death. Has also taken into account Rec 12 of RCIADIC. #JusticeForTanyaDay

(Apologies- internet cutting in and out so missing a few things.)

Scope a: cause of death. Dr Michael Burke conducted autopsy- no findings to indicate underlying brain pathology. Cause of death- left cerebral haemorrhage of traumatic origin, also noted- liver cirrhosis. #JusticeForTanyaDay

Scope b: whether earlier recognition of intercranial haemorrhage would have altered the outcome. Assoc Prof Laidlaw suggested that this could have been possible- but if she survived would have had significant neurological deficit. #JusticeForTanyaDay

Would she have survived with urgent and appropriate medical treatment? Assoc Prof Laidlaw suggested that under ideal circumstances it would be unlikely that Ms Day would have survived. #JusticeForTanyaDay

However, there was a chance she could have survived with severe disability given the opportunity to access immediate medical treatment. Coroner accepts this evidence- opportunity lost for her survival. #JusticeForTanyaDay

Scope c: circumstances in which the death occurred. VLine employee Irvine’s choice to remove Ms Day from the train. Irvine formed view she was unruly and contacted conductor to alert police. #JusticeForTanyaDay

Assessment by Irvine that Ms Day’s safety was threatened in allowing her to proceed in current state. His decision was to call police because of risk of falls etc. he didn’t contact a relative, carer or ambulance but instead the driver, who contacted police. #JusticeForTanyaDay

Evidence from other staff and passengers on train- Irvine stated he had problems/behavioural issues with Ms Day and was disturbing passengers. However, later agreed that her statement was not unruly. #JusticeForTanyaDay