Coroner delivers critical findings over death of Ms Wynne

While the WA Coroner’s findings are critical of WA Police and the WA Health Service, the investigation falls short of delivering justice to Ms Wynne’s family and creating much-needed change in how police respond to mental health crises.

A WA Coroner has released his findings into the death of Ms Cherdeena Wynne, a 26-year-old Noongar Yamatji mother of three who stopped breathing whilst she was being detained by WA Police the side of the Albany Highway at Bentley.

Her family have been left doubly traumatised as Ms Wynne’s late father, Warren Cooper, died whilst in the care and custody of WA Police almost 20 years before Ms Wynne’s death.

The Wynne family say that, although the findings of the Coroner are critical of the police, there is no accountability or justice for them in the recommendation and the family is concerned that without the systemic changes they sought more preventable deaths will occur. Ms Wynne’s relatives do not want other Indigenous families to suffer the loss of their loved ones in custody.

Importantly, this case highlights the issues and very real danger of police acting as first responders to mental health crises without appropriate support from mental health professionals.

After all, Ms Wynne was not being detained or arrested for any criminal conduct. She was stopped by police who were assisting an ambulance team to get her into a mental health facility.

“I know that Cherdeena was already afraid of the police because of the way her dad died in their care and custody” – Aunty Jennifer Clayton, Ms Wynne’s grandmother

The Coroner’s findings

  • The family accepts the Coroner’s finding that the restraint of Ms Wynne in the prone position was a contributing factor in her death
  • The Coroner stated his concerns about the removal of the one-to-one supervision of Ms Wynne at the hospital and the lack of mental health beds available, which contributed to her escaping mental health care
  • The Coroner found that a police officer who arrested Ms Wynne by the side of the Albany Highway drove at an unsafe speed, which would have frightened Ms Wynne further and put her life in danger
  • The Coroner observed that Ms Wynne was not offering significant resistance, that the police were in control of her and that she could have been moved to a safer place away from the highway with a minimum of force
  • The Coroner also found that the use of the prone position to handcuff Ms Wynne was close to the threshold of becoming unreasonable, which would have made it unlawful, but he ultimately declined to make that finding.

The Coroner’s most critical findings

The Coroner reserved his most critical findings to last when he found that:

  1. Officer Williams erred in maintaining his leg hold on Ms Wynne’s back for longer than was necessary and that this delayed her being lifted from the prone position; and
  2. That four police officers erred in failing to ensure that Ms Wynne’s breathing was properly monitored when she was in the prone position.

The family agrees with the Coroner’s criticisms of the treatment of Ms Wynne by the WA Health Service and the WA Police Force.

What the family is demanding as a pathway for justice

“We feel so let down by the police. First her dad Warren Cooper died in police custody and now his daughter Ms Wynne both aged 26 years old. This is generational trauma, there is a ripple effect in families” – Aunty Jennifer Clayton, Ms Wynne’s grandmother

  • Ms Wynne’s family is demanding cultural change in WA policing. They want an apology and real accountability for the way that Ms Wynne was treated by police.

  • They are demanding that police should not be first responders to those experiencing a mental health crisis.

  • They want independent investigations of Police conduct. They don’t want police investigating police, and they criticise the poor quality of the police investigation in this case.

  • They have also asked for improved cultural safety for Indigenous families in the WA Coroners Court.

Lessons are not enough to prevent more Aboriginal deaths in custody  

The family agrees with the Coroner that WA Health Service and WA Police failed Ms Wynne. The fact that the Coroner claims that they have learned some lessons and made some improvements gives Ms Wynne’s family little comfort and there is little to show for it in the day-to-day treatment of Aboriginal people and little insight shown by the police witnesses in Court.

Ms Wynne’s grandmother Aunty Jennifer Clayton said:

We are heartbroken to read about failure after failure in the lead up to Ms Wynne’s death. How long will it take for the police to learn these lessons and follow through with improvements and recommendations to prevent future deaths?”

We always believed that Officer Williams maintained his leg hold on Cherdeena’s back for longer than was necessary but we were never told that the four police didn’t even bother to check her breathing when she was so vulnerable and was being held down in a dangerous hold – hold known as the ‘prone position’. Shouldn’t they care for a young human being? She committed no crime, she was confused. She was not well and very distraught about her baby being removed from her. We know this because she had phoned family members asking for help to get baby back. Ms Wynne just needed help.

National Justice Project Solicitor Karina Hawtrey said:

The National Justice Project had argued for stronger recommendations and are disappointed with the single recommendation about the need further training. This flies in the face of the serious criticisms that the Coroner has levelled at the WA Police and its Internal Affairs Unit. The recurring problems of a lack of safety for First Nations people and those with mental health issues in their interactions with police should have been addressed.”




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