Analysis : the last day of hearings into the Yorta Yorta woman’s death in custody was an opportunity for police to apologise and promise policy change. They failed on both counts

Two hours into the evidence of the officer nominated by the chief commissioner of Victoria Police to give evidence at the inquest into the death in custody of Aboriginal woman Tanya Day, coroner Caitlin English called time.

“This witness was asked at my direction to come to court,” English said, interrupting a painful cross-examination from Peter Morrissey SC who was trying, at the instruction of Day’s family, to get some responses from police to the failures that led to their mother’s death. “Unfortunately she’s not able to cover quite a lot of the territory that I was hoping for.”

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That territory was the training of police officers with regards to cultural awareness and unconscious bias and, more crucially for the family, the management of detainees in police custody. They also wanted to learn if there had been an internal review or even a memo sent around about Day’s death: any sense of acknowledgement within the police force that a woman had died.

Morrissey was indignant.

“The witness has been put here specifically because she doesn’t know,” he said.

Earlier he said the witness, superintendent Sussan Thomas, had been appointed as a “decoy”.

It was not Thomas’s fault, he said. Thomas, who was in charge of the Aboriginal and youth portfolios in Victoria Police’s priority communities division, had been dumped in it.

Police began their serious incident investigation into Day’s time in custody on 6 December 2017, just hours after she had been taken from Castlemaine police station in an ambulance and 16 days before she died. The first coronial directions hearing was heard exactly 12 months later. Lawyers for Ms Day’s family had been requesting Victoria Police nominate a senior person to give evidence on policies, procedures and training for six months. The inquest itself began three weeks ago.

Play Video 4:52 CCTV shows Tanya Day falling multiple times in police cell – video

Yet Thomas was only notified two days before the inquest was scheduled to conclude. Her 14-page statement was only received at 9.51am on Friday, the final day. Rachel Ellyard, counsel for the chief commissioner, spent the lunch break frantically obtaining and photocopying fact sheets and training material on unconscious bias, only for Thomas to say it was not really her area.

The inquest is now over but for submissions and findings. There’s no opportunity to go back over this material with another witness.

Outside court, Day’s eldest daughter, Belinda, said the decision of the chief commissioner not to provide a witness that could “answer the questions that the court is asking” was insulting.

“[It] just shows that there’s a lack of respect for the court,” Belinda Day said. “The coroner herself has requested that witness and her inability to answer those questions just shows a disregard to that.”

Inquests into deaths in custody follow a pattern.

First the officers directly involved, police or prison, give evidence about their involvement with the deceased, pertinent details of which they cannot recall.

Then comes the medical evidence and opinions from expert witnesses, who say the care of the deceased person was inadequate.

Cases where care was adequate do not make the news. An investigation by Guardian Australia found Indigenous women were the least likely of any group to have received all appropriate medical care prior to their death in custody.

The last phase of the inquest is always an executive of the responsible agency who will tell the family the agency is sorry for their loss but has not, according to folders of tabbed and highlighted documents, done anything wrong.

They will explain that the officers involved had received a reprimand for any failure to follow procedure and set out a range of changes that have been introduced in an attempt to head off adverse findings by the coroner. This strategy almost always works.

Occasionally, as was the case with Ambulance Victoria executive director of clinical medicine Michael Stephenson, the apology will ring true, the promise of change genuine.

“I am deeply sorry for your loss, deeply sorry for our disrespectful care, and for lack of regard we showed Tanya on the day,” Stephenson told Day’s on Tuesday.

“It’s a very dark moment for our organisation to have been confronted with that, and as I say I’m deeply sorry and I’m deeply sorry to all the Aboriginal people who are offended by that.”

Thomas, prompted by Morrissey to offer a similar apology, had clearly not been briefed.

“Personally I am very sorry for the family,” she said. “We definitely are sorry for your loss and sorry for the pain and personally it impacts on me, I want you to know that.”

Day’s family have demanded a formal apology from both Victoria Police and V/Line.

The purpose of the expert departmental witness is to give an indication to the coroner of which changes the agency would be prepared to adopt and which would be considered unfeasible. It is to make the inquest more efficient and the recommendations more targeted.

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In the 2016 inquest into the death of Yamatji woman Ms Dhu, assistant commissioner Duane Bell said police had already requested discretion on arresting someone on a warrant for unpaid fines. This was noted in the coroner’s findings.

Victoria Police, for reasons known only in its high offices, elected not to provide that assistance.

Thomas, asked why she thought she had been called to give evidence, said she was “here to talk about all the good work that is occurring across Victoria Police, and the policies as well.”

When someone has died, it is not acknowledgements of country or dancing with children at an Aboriginal Justice Forum that matters.

If Victoria Police’s commitment to reconciliation is to mean anything, they have to show up when it counts.