A pregnant woman killed in a violent assault by her defacto may have survived if a 000 calltaker had dispatched police and ambulance officers instead of passing the emergency call off as a hoax, a WA coroner has found.
The revelation was made in findings by Deputy Coroner Evelyn Vicker on Thursday after an inquest into the death of Shionah Violet Teneille Carter, 26, who died after a prolonged attack by her partner in August 2010.
David John Martin, 28, was sentenced to life imprisonment with a minimum term of 15 years in 2011 for murdering Ms Carter at their Beechboro unit while affected by methamphetamine, cannabis and alcohol. He had not slept for five days leading up to the murder.
After returning home from a night of partying, Martin bashed Ms Carter repeatedly in a jealous rage, using multiple objects including a piece of wood.
He then sexually assaulted the woman, who was three-months pregnant, while she was severely injured before ordering her to have a shower to clean her bloodied body.
The inquest heard two 000 calls at 7.28pm and 7.53pm on August 14, 2010 did not register a clear voice on the other end of the line.
But a third 000 call at 3.21am the following morning, which was patched through to police calltaker First Class Sergeant Andrew Bell, was a male caller who provided a false name and location inconsistent with the caller line identification (CIL) provided on-screen to the calltaker. Moaning and whimpering sounds of a distressed person could be heard in the background.
When Sergeant Bell requested the caller identify his location, Martin hung up. The policeman tried to re-establish contact through information provided by the caller line identification, but was unsuccessful and no further action was taken.
About 50 minutes later, police received 000 calls from several neighbours and police were dispatched to the Ottawa Crescent unit.
By then Ms Carter had suffered further assault which resulted in her death due to asphyxiation and cardiac arrest. She died sometime between 3:21am and 4:23am on August 15, 2010.
"The caller line identification assisted the calltaker with the veracity of the antecedents of the caller, but could only establish the location from which the call was made," the coronial report found.
"When Bell was unsuccessful in reconnecting the call, he did not populate a computer tasking screen for dispatch of a police vehicle to the CLI address. Nor did he request the attendance of an ambulance at the same location.
"While there are hoax calls to 000 emergency services organisations, the background moaning in the given call was something Bell acknowledged required he act in accordance with the protocols regardless of the potential for hoax callers.
"He was unable to explain why that had not occurred and was clearly distressed at his failure to task either a police vehicle, or ambulance to the CLI address. It was generally accepted police would have been able to attend at the CLI address."
In delivering her findings, Ms Vicker recommended WA Police consider automated electronic alerts in their computer aided dispatch system so information about possible dangers at an address or posed by a caller could be fed between the CAD job and 000 calltaker.
"Alerts should be linked to the confirmed caller line identification data (name, address and number) and may include such things as previous domestic violence incidents at the address, or those involving the caller; previous calls from the number to 000 within the last 15-24 hours; violent offences attracting imprisonment (linked to the caller, subscriber, any other names entered into CAD by the call taker)," she said.
Ms Vicker also recommended that the 3.21am 000 call be used as a practical case study for 000 calltakers undergoing initial training in the job as well as being used as a refresher case study for all calltakers.
"It is clear the deceased's partner's actions both caused and contributed to her death," she said. "However, it is possible medical intervention between 3:30am and 4:00am may have prevented her death.
"Had Bell dispatched police or an ambulance to the address on the CLI in accordance with police policies and procedures, it is possible the deceased's death could have been prevented.
"It is not clear, however, as to whether the deceased's overall prognosis by that time would have been for a sustainable recovery, depending upon the level of further assault and injury she had incurred."
At the inquest, St John Ambulance WA clinical services director Ian Jacobs, who is also a professor of resuscitation and pre-hospital care at Curtin University, said he was unable to determine if Ms Carter could have been resuscitated if paramedics had been dispatched after the 3.21am 000 call.
But PathWest Dr Jodi White said any intervention between 3.21am and 4am, before her cardiac arrest may have saved her life.
Sergeant Bell was initially stood down from duty and issued with a "loss of confidence notice" but was returned to operational duties for his "exemplary record". He has since retired from WA Police.
A St John Ambulance spokesman declined to comment on the findings.
Comment has been sought from WA Police.
