Audit of Victoria Police's oversight of serious incidents (key findings)

IBAC’s role regarding Victoria Police

The Independent Broad-based Anti-corruption Commission (IBAC) plays a vital role in providing independent oversight of Victoria Police. IBAC’s role includes:

  • receiving complaints and notifications about corrupt conduct and police personnel conduct (including complaints received by Victoria Police and mandatorily reported to IBAC)
  • assessing those complaints and notifications to determine which will be referred to Victoria Police for action, which will be dismissed, and which will be investigated by IBAC
  • providing or disclosing information to the Chief Commissioner relevant to the performance of the duties and functions of Victoria Police
  • reviewing investigations of selected matters referred to Victoria Police to ensure those matters were handled appropriately and fairly
  • oversighting deaths and serious injuries associated with police contact pursuant to a standing ‘own motion’
  • conducting ‘own motion’ investigations about police personnel conduct or corrupt conduct
  • conducting private and public examinations to assist investigations into police personnel conduct and, in the case of public examinations, exposing systemic issues, encouraging people with relevant information to come forward and to serve as a deterrent to others
  • ensuring police officers have regard to the Charter of Human Rights including through reviews and audits of Victoria Police complaint investigations
  • undertaking research and other strategic initiatives, including auditing how Victoria Police handles its complaints
  • informing and educating the community and Victoria Police about police misconduct and corruption, and ways it can be prevented.

When an individual dies or is seriously injured following an interaction with police, Victoria Police conducts a review of the incident, known as an ‘oversight’. Victoria Police’s oversight seeks to identify whether the incident was preventable or whether changes could be made to police policies or practices to prevent similar incidents from occuring. Victoria Police also examines whether the investigation of the death or serious injury met the standards expected for handling these serious incidents. Victoria Police initiates these oversights1 whenever one of the following serious incidents2 occurs:

  • a death or serious injury resulting from contact between police and the public
  • a death or serious injury to a person in police custody
  • an attempted suicide by a person in police custody
  • an incident involving the discharge of a firearm by police
  • an escape from custody
  • any serious vehicle collision involving police.

The IBAC audit

To assess how effectively Victoria Police oversights these serious incidents involving its officers, IBAC audited more than 140 oversight files closed by Victoria Police during 2015/16.

IBAC examined whether Victoria Police’s oversight adequately addressed a range of issues including:

  • how thoroughly the oversight examined the incident and any associated investigation
  • whether the oversight was impartial
  • whether conclusions or recommendations were justified
  • the adequacy of record keeping in such matters
  • how long the oversight took.

What we found

IBAC identified a number of deficiencies in how Victoria Police oversights serious incidents. Problems identified included:

  • Conflicts of interest were poorly identified and managed, and almost a third (32 per cent) of oversights did not include the mandatory conflict of interest form. Where conflict of interest forms were on file, they were often incomplete, and the identified conflicts were poorly managed.
  • Half (51 per cent) of oversights failed to consider evidence that should have been included. The audit found there was an over-reliance on police statements in relation to serious incidents. Concerningly, many oversights did not include statements from independent witnesses that could assist in verifying the accounts given by the police officers involved.
  • Almost a third (32 per cent) of oversights showed inadequate supervision, including a failure by supervisors to address significant shortcomings in the oversight.
  • Despite human rights being a key oversight principle, almost two-thirds (61 per cent) of oversights did not address human rights. Where oversights did discuss human rights, many failed to identify relevant human rights issues, did not address rights in sufficient detail, or demonstrated a poor understanding by mischaracterising other issues as ‘rights’.
  • More than a third (37 per cent) of oversights took longer than the permitted time of 90 days to complete. These delays were mostly caused by poor procedures by Victoria Police including the slow movement of physical files and the need to undertake further work to correct issues with files that were identified by supervisors.
  • A pattern of deficiencies was identified in oversights involving the Special Operations Group (SOG)3 including poor management of conflicts of interest and a lack of thorough oversight. This is particularly concerning given the serious nature of the incidents that require SOG involvement.
  • While Victoria Police notified IBAC of the majority of serious incidents that were examined by this audit, there was no statutory requirement to do so (unless they were the subject of a complaint).


IBAC’s audit identified areas for improvement in how Victoria Police oversights these serious incidents. IBAC has made a number of recommendations to Victoria Police including:

  • improving how conflicts of interest in oversights are identified, recorded and managed
  • providing officers with clearer information and training on the Victorian Charter of Human Rights to improve understanding of the human rights issues raised by serious incidents
  • improving the supervision of oversights to deliver greater consistency in relation to reclassification, timeliness, record keeping and how deficiencies are addressed
  • ensuring oversight by Victoria Police’s Professional Standards Command of incidents involving the SOG
  • working with IBAC to improve the system for notifying IBAC of all deaths and serious injuries that follow contact with Victoria Police.4

Victoria Police has acknowledged and accepted the recommendations.

To read the full report, including all key findings and recommendations, please visit Audit of Victoria Police's oversight of serious incidents in the publications section of the IBAC website.

Next steps

IBAC will monitor Victoria Police’s implementation of the audit’s recommendations. IBAC has requested that Victoria Police provide an interim report on its implementation of the audit’s recommendations by September 2018 and a final report by March 2019.

The audit is part of a broader program of audits IBAC conducts of Victoria Police. These audits are an important part of IBAC’s independent oversight of Victoria Police and our work to expose and prevent corruption and police misconduct. They identify ways to help strengthen Victoria Police’s complaint systems and hold it accountable following serious incidents.

1 These oversights are classified as C1-8 (incident investigation and oversight) files by Victoria Police’s Professional Standards Command.

2 For the purposes of IBAC’s audit, the term ‘serious incident’ is used to collectively refer to incidents that are overseen through Victoria Police’s C1-8 file process. This includes what Victoria Police refers to as ‘death or serious injury incidents’ – which some other police organisations refer to as ‘critical incidents’ – as well as other incidents requiring C1-8 oversight such as escapes from custody.

3 The SOG is a specialised unit within Victoria Police that responds to incidents such as sieges, hostage situations, bomb responses, and assists with the apprehension of armed offenders and dangerous suspects.

4 In September 2017, in response to the audit, Victoria Police commenced notifying IBAC by automated email whenever an oversight file is created. This process should ensure IBAC is notified of all oversight files.