A Victorian coroner has ruled that a patient found dead in a pool of blood at a Melbourne psychiatric hospital did not kill himself and that the "setting" in which he died may have influenced a "seriously flawed" Victoria Police investigation.
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Coroner Paresa Spanos' finding is an embarrassment for Victoria Police after detectives quickly determined 52 year old Fred Williamson's March 30 2008 violent death did not involve anyone else and his family was told that he had either committed suicide or died as a result of misadventure.
Williamson had been in the care of Victoria's mental health system for 32 years when he was found dead on another patient's bathroom floor at the Austin Hospital's psychiatric unit in Heidelberg. His doctors had never classified him as suicidal or having a tendency to self-harm.
He was found with severe head injuries and a plastic bag twisted tightly over his head. But little or no forensic evidence was gathered from the scene.
Fairfax Media in 2011 revealed the bizarre circumstances of Williamson's death and his family's displeasure with the initial police investigation and assumption he was responsible for his own death.
Their concerns were vindicated in a series of strong findings made by Coroner Spanos earlier today.
"I find that the weight of evidence supports a finding that Freddy's injuries were not self-inflicted and that he died in circumstances of assault by a person whose identity I am unable to ascertain," Coroner Spanos concluded.
Coroner Spanos has referred the matter to the Director of Public Prosecutions because she had formed the belief that "an indictable offence may have been committed".
However, she said the referral may be "futile" because a suspect was unable to be identified.
Coroner Spanos found the detectives and officers called out to attend the scene "failed to secure the scene and ensure a thorough forensic investigation''.
"I find that the weight of evidence supports a finding that the investigation was inadequate, indeed that the errors made by the police who attended the scene are largely irremediable."
"The evidence does not enable me to determine why this investigation went so terribly awry. It is difficult to imagine that police members attending a similar scene in a public access bathroom or toilet, or even in a domestic setting, would so readily discount the possibility of suspicious circumstances,
"I do not suggest anything deliberate or even conscious on the part of the police members who attended the scene, but absent another explanation for their failure to recognise a potentially suspicious scene, leaves open the possibility that the setting in which Freddy died may have played a role."
