CORONER Jacinta Heffey has delivered the findings of a inquest into the death of a man who took his own life while in custody at Echuca Police Station.
Stephen Niit, 45, died on December 23, 2009, after using his dog's collar to take his own life.
Mr Niit had been allowed to take his dog, Tilly, into the cell with him.
Mr Niit, a paramedic from Doncaster in Melbourne’s east, had a long history of alcohol abuse and depression and had been released from psychiatric care six days before his death.
"A large portion of the evidence heard in this inquest related to the alleged failure of the police members to identify Mr Niit as a vulnerable person," Coroner Heffey states in her report.
"This situation raises the whole issue of capacity to recognise vulnerability when it is complicated by a degree of intoxication."
Coroner Heffey said assessing "suicidality" was an extremely difficult skill.
"The suggestion of 24-hour phone or online access to forensic mental health nurses/doctors as suggested by the submission of the Loddon Campaspe Legal Centre is superficially attractive but I wonder at its usefulness," she said.
"Mr Niit gave no indication to Echuca police that he was intending to kill himself ... the answer, in my view, lies in applying monitoring and checking practices as set out in the Standard Operating Procedures and the Victoria Police Manual, and removing all hanging points and any item that could be used to self-harm.
"No exceptions should be made, even if motivated by compassion.
"A departure from the rules may, as in this case, lead to totally unexpected outcomes."
Cornoner Heffey recommended Victoria Police institute an "alert" process to be widely broadcast among members providing information about deaths and "near-misses" in respect to people in custody in police cells.
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