Indigenous Deaths in Custody: Part E Profiles: Indigenous Deaths in Custody 1989 - 1996

Part E Profiles: Indigenous Deaths in Custody 1989 - 1996

New South Wales
Victoria
Queensland
Western Australia
South Australia
Tasmania
Northern Territory
Other Deaths in Custody
Glossary


Queensland

3QLD 13/7/89 26

M

Police Townsville Watchhouse Self-inflicted
5QLD 5/8/89 21

M

Police Townsville Watchhouse Drugs
11QLD 8/1/90 30

F

Prison Brisbane Women. s Prison Injury
13QLD 2/4/90 21

M

Prison Rockhampton Prison Self-inflicted
14QLD 3/4/90 24

M

Prison Rockhampton Prison Self-inflicted
21QLD 17/10/90 28

M

Police Mornington Island Watch Injury
22QLD 12/1/91 17

M

Prison Lotus Glen Prison Self-inflicted
25QLD 2/5/91 34

M

Police Rockhampton Watchhouse Natural
32QLD 14/11/91 44

F

Police Palm Is. Watchhouse (TH) Injury
34QLD 22/12/91 17

M

Prison Sir David Longlands Prison Self-inflicted
38QLD 25/5/92 58

F

Police Brisbane Lockup Natural
41QLD 12/11/92 24

M

Police Ross River, Townsville Injury
43QLD 4/12/92 27

M

Prison Townsville Prison Self-inflicted
45QLD 7/4/93 21

M

Prison Arthur Gorrie Remand Centre Self-inflicted
53QLD 7/11/93 18

M

Police Brisbane Natural
55QLD 9/1/94 22

M

Prison Lotus Glen Prison Natural
58QLD 12/3/94 32

M

Prison Rockhampton Prison Natural
59QLD 2/4/94 19

M

Prison Arthur Gorrie Remand Self-inflicted
64QLD 4/7/94 35

M

Prison Townsville Prison Self-inflicted
69QLD 1/2/95 20

M

Prison Sir David Longlands Prison Self-inflicted
74QLD 20/4/95 27

M

Prison Borallon Prison Self-inflicted
79QLD 19/7/95 32

M

Prison Sir David Longlands Prison Self-inflicted
88QLD 8/12/95 17

M

Prison Sir David Longlands Prison Self-inflicted
90QLD 1/1/96 23

M

Prison Townsville Prison Self-inflicted
94QLD 9/3/96 13

M

Police Townsville Injury

3QLD

Male 26, died on 13 July 1989
Townsville Watch-house, Qld
Self-inflicted hanging

Coronial Inquiry Coroner B D Barrett at Townsville Coroner's Court

Finding handed down 25 January 1990

Finding

Hanging. The deceased met his death by his own willed actions.

Summing up

Circumstances of Death

The deceased had been arrested for driving under the influence of alcohol and for driving while disqualified. He was placed in what the Coroner described as an enclosed cell, in which occupant vision is impossible, at around 3.00am and told he would remain there for a period of four hours.

At approximately 4.40am, an officer discovered the deceased hanging from his cell door with pieces of shredded bedding material around his neck. Immediate action was taken to revive the deceased. Resuscitation was attempted by police and the ambulance officers who conveyed him to Townsville General Hospital, where further attempts to revive him were unsuccessful. The deceased was pronounced dead at 5.07am.

Issues

The deceased had previously been arrested 34 times for offences relating to drunkenness. He had a blood alcohol content of .21% on this occasion. Police reported that he was quiet and resigned after he was charged and told he would be detained for four hours.

The Coroner found that the deceased 'on the evidence before [him], at no stage acted in a manner that aroused the attention of either officer'. He had requested and received a packet of cigarettes in the vicinity of 3.15am and was observed sitting on his bed smoking a cigarette at approximately 3.50am.

Recommendations

The Coroner recommended to the Commissioner for Police that video surveillance equipment be installed in all enclosed cells where occupant vision is impossible. He also pointed out that he made the same recommendation in February 1989 following a death in similar circumstances, but no action was taken.

Royal Commission Recommendations

R15 Responsibility of institutions to report on implementation of Coroner's recommendations within three months. (IR44)

R16 Distribution of implementation reports on Coroner's recommendations. (IR44)

R137 Police training and instructions to require checks of detainees; specified intervals between checks on the health and safety of detainees; monitoring/ checking procedures; more regular checks for detainees at risk. (IR15, 24)

Social Justice Commissioner

Comment

The two page Coronial Report contained few details of the death. The finding that there was nothing to indicate the deceased was at risk seems to be based purely on police evidence. No details were given of Queensland's post-death investigation procedure, which was later to be criticised by the Royal Commission as overly dependent on police reports. There is no reference to an autopsy. There is no consideration of procedures for checking prisoners. There is no indication of whether the deceased was alone in the cell.

The Royal Commission's Interim Report was released at around this time. It made numerous recommendations about the need for close surveillance of intoxicated persons and scrutinising of cells to remove items with the potential for self-harm. The Interim Report recommendations were not mentioned by the Coroner. The police sergeant conducting the investigation stated that he had never seen the Muirhead Interim Report.

The Royal Commission (recommendation 125) advocated screening forms to elicit information on the detainee's psychological and medical condition, and careful assessment of these forms, which may have led to preventative measures being taken.

The Coroner's recommendation that video surveillance equipment be installed should be considered in light of the Royal Commission's recommendation (139) that the use of electronic monitoring should not take the place of personal cell checks.

Additional Royal Commission Recommendations Breached

R7 Specific State/Territory Coroner for inquiries. (IR44)

R8 Development of specific rules for inquiries and inquests. (IR44)

R12 Legal requirement for Coroner to consider how the person was treated before death. (IR46)

R13 Coroner to recommend ways to prevent further deaths. (IR44)

R 35 Police investigations should: be approached on the basis that the death may be a homicide; inquire into the arrest or apprehension, lawfulness of custody and treatment and supervision of the deceased; and thoroughly examine the scene of death and forensic exhibits. (IR55)

R95 Where motor vehicle offences are a major factor in imprisonment, programs to be consultatively developed to reduce incidence.

R125 A screening form to be introduced for detainees on reception into police custody.

R127f(i) Rules for care and management of Aboriginal prisoners at risk who are intoxicated.

R165 Elimination/reduction of items with potential for self-harm.(IR23)

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5QLD

Male 21, died on 5 August 1989
Townsville Watch-house, Qld
Alcoholism

 

Coronial Inquiry Coroner D G Evans at Townsville Coroner's Court

Finding handed down 11 December 1990.

Finding

The cause of death was acute and chronic alcoholism.

Summing up

Circumstances of Death

The deceased was charged with public drunkenness at about 11.30am on the day of his death. He was unconscious at the time of arrest and had to be physically carried by two officers to the police van and the watch-house. At the watch-house he was placed in a coma position on the floor of the 'drunk cell' with a number of others arrested for intoxication. The charge was not read due to the deceased's unconscious state.

Visual checks were made from outside the cell until about 3:45pm when a police officer entered the cell and found the deceased with no movement or pulse. Medical aid was not considered as police believed that life was already extinct.

Issues

The deceased was arrested after being observed lying beside the toilet in Hanran Park Townsville. This was the fourth day in a row he had been arrested for public drunkenness. When he was picked up by police he had apparently been unconscious for some time. There were black ants crawling over his clothes and hair.

At the inquest all the police officers testified that they were unaware of the Interim Report recommendations concerning arrest and detention of persons suffering from severe intoxication.

Recommendations

1. That medical assistance immediately be sought when persons who are known to be habitual drinkers are admitted to watch-houses;

2. That persons in charge or working in watch-houses receive adequate training so they are able to identify the differences between persons, asleep, unconscious, needing help, and when medical attention should be sought;

3. That police be given the same training;

4. That persons in charge of watch-houses make their own observations regarding health of prisoners; and

5. Implementation of Muirhead Report recommendation 13.

Royal Commission Recommendations Breached

R127f(i) Rules for care and management of Aboriginal prisoners at risk who are intoxicated.

R133 Training of police officers to recognise those in distress or at risk. Such training to include general health status of Aboriginal population. More intensive training for officers whose work is cell guard duties only. (IR14)

R135 People unconscious or not easily roused to be taken to a medical service, not a watch-house. (IR12)

R136 People found unconscious or not easily roused to have immediate medical care. (IR13)

R137 Police training and instructions to require checks of detainees; specified intervals between checks on the health and safety of detainees; monitoring/ checking procedures; more frequent checks if detainee at risk. (IR15)

Social Justice Commissioner

Comment

This was the second death in less than one month in the Townsville Watch-house, both deaths raising issues relating to the detention of intoxicated persons. Unfortunately, the Coronial Report consisted of half a page of findings and another half page of recommendations. A different coroner was used, reducing the quality of scrutiny.

This death raises the inappropriateness of criminal penalties for public drunkenness. It is totally unacceptable to arrest an unconscious person and leave them without care or supervision in a police cell.

At the inquest it was stated that a newly issued police memorandum gave police the discretion to take intoxicated people to hospital. This does not give effect to Royal Commission recommendation 81 which calls for statutory duty based on legislation, for police, where possible, to use alternatives to police cells for intoxicated persons. The testimony of police in later cases indicates that, in any event, they are unaware of new guidelines or standing orders and believe that under Queensland legislation they must arrest intoxicated persons and take them to police cells.

Training police officers to handle or detect the health risks facing intoxicated persons is especially important given the Queensland Government's inaction on decriminalising public drunkenness and the lack of alternatives to police custody. A medical assessment screening form completed prior to placement in a cell, as recommended by the Royal Commission (Recommendation 125), would likely have alerted police to the inappropriateness of their actions. The case also illustrates the importance of having a medical presence at watch-houses (Recommendation 127).

Other Royal Commission Recommendations Breached

R7 Specific State/Territory Coroner for inquiries. (IR44)

R8 Development of specific rules for inquiries and inquests. (IR44)

R12 Legal requirement for Coroner to consider how the person was treated before death. (IR46)

R35 Police investigations should: be approached on the basis that the death may be a homicide; inquire into the arrest or apprehension, lawfulness of custody and treatment and supervision of the deceased; and thoroughly examine the scene of death and forensic exhibits. (IR50,51,55)

R79 Abolition of offence of public drunkenness. (IR3)

R80 Adequately funded custodial care to accompany abolition of this offence. (IR4)

R81 Statutory duty to consider and use alternatives to police detention of intoxicated persons. (IR5)

R125 Screening form to be routine part of reception into custody and to be evaluated.

R127a Regular medical presence in watch-houses in capital cities and other major centres.

R214 Support for community policing with involvement of Aboriginal communities and organisations in developing procedures in areas where Aboriginal people live or gather.

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11QLD

Female 30, died on 8 January 1990
Brisbane Women's Prison, Qld
Stabbing Injury

Coronial Inquiry Not conducted

Social Justice Commissioner

Cause of Death

The cause of death was massive internal haemorrhage and stab wounds to chest and neck. 1

Circumstances of death

Unknown

Issues

The decision by the Coroner not to carry out an inquest is disturbing. The fact that a criminal trial was to follow for an offence relating to the death in custody should not exclude the role of the Coroner. Unlike the court, the Coroner can dispel suspicions and look at broader issues underlying the deceased's arrest and imprisonment. The Coroner can examine the adequacy of structures and procedures in place to supervise prisoners. The Coroner can look at organisational matters which may have contributed to the death, and ways of preventing similar deaths. A full inquest, which looks at the quality of the care and supervision of the deceased prior to death, should be held.

Royal Commission Recommendations

R11 All deaths in custody be required by law to be the subject of a coronial inquiry culminating in a formal inquest. (IR45)

R12 Coroners to investigate not only cause and circumstances of death, but also quality of care, treatment and supervision of the deceased prior to death. (IR46)

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13QLD

Male 21, died on 2 April 1990
Rockhampton Prison, Qld
Self-inflicted hanging

Coronial Inquiry Coroner K P Lynn at Rockhampton Coroner's Court

Finding handed down on 5 November 1990

Finding

The death was due to hanging, and there were no suspicious circumstances surrounding the death of the deceased.

Summing Up

Circumstances of death

The deceased was serving sentences for offences committed against the Prisons Act whilst in custody. He had been confined to a detention unit after a fight with a prison guard. He reportedly refused to answer when challenged by the guard about being handed something by another person. The prison guard then followed the deceased into the gymnasium where heated words were exchanged. The deceased was then found to have approached [the guard] and punched him in the face.

After a struggle, the deceased was restrained by a number of officers and conveyed to the chief's office still struggling. He was subsequently handcuffed and taken to the detention unit. That afternoon the deceased became agitated because he believed he saw a prison officer spitting in his food. He was given unspecified medication by a prison officer serving as a medical orderly. He was last spoken to by a fellow inmate at 8pm.

During a head count at about 11:15pm the deceased was observed through the cell door, but a significant portion of his body was obscured by a towel hanging over the grill on the door. He was observed in the same position some three hours later. Suspicions were raised, but cell keys were not carried by prison officers during head counts and time was lost before his cell door could be opened. When officers gained access they found that one end of a piece of a sheet was knotted around his neck with the other end fastened to a mesh grill at the front of the cell. The deceased was pronounced dead at 4.05am.

Issues

The deceased had a history of hypersensitivity. The Coronial report indicated that he had recently been prescribed medication for depression, but did not take it. The Coroner found that he clearly had difficulty accepting the restraints imposed by life in prison. He had charges relating to over sixty offences, including assault occasioning bodily harm, street offences, unlawful use of a motor vehicle and break and enter. During a period of incarceration from 1987 to 28 January 1990, the deceased was breached 20 times for offences under the Prisons Act.

The deceased had been seen by a psychologist several times in the two months preceding his death. Initially the deceased was considered at risk and referred to a psychiatrist. There was no indication that he actually saw a psychiatrist. The Coroner asserted the psychologist reported that on 22 March the deceased 'appeared to have settled down considerably since the last time I saw him, at this time I did not have any concern that he was in any way contemplating suicide and I did not consider that psychiatric help was needed'.

Recommendations Nil

Royal Commission Recommendations Breached Nil

Social Justice Commissioner

Comment

The coronial findings were cursory, consisting of three pages with no recommendations despite revealing questionable practices, such as prison officers not carrying keys during head counts. The Coroner was a layperson and not a magistrate. The findings did not consider possible provocation by a prison guard who had fought with the deceased.

The administrator of the Rockhampton Aboriginal Legal Service told journalists at the time of the death that inmates at the prison were discontent and had reported 'intimidation, harassment and unfair disciplinary action from prison officers, including the denial of privileges for petty offences.' 2 The number of offences against the Prisons Act might be seen to lend support to the claim. The recommendation that imprisonment be a last resort would seem to conflict with the extended detention for summary offences under the Prisons Act (R92). While this assessment may not have been correct, public suspicions of poor custodial care should be dispelled by a coronial inquest.

Remarks indicating the deceased was not at risk of suicide, although quoted in the past tense, were represented in the Coroners findings as being from records made on the day of the psychologist's last examination.

The deceased had been involved in a violent incident on the day he died, and notes on the file from the psychologist indicated that he was hypersensitive and would have reacted badly to violence. This file note should have been part of a consideration of precautions for assessing his risk status before placing him alone in detention in a cell. Instead, he was seen by a prison officer serving as a medical orderly. No special precautions were taken, and the deceased had been three hours without a cell check when he was found. The earlier cell check was seemingly made with such lack of attention that it failed to establish that the deceased was already hanging.

There seems to have been no Aboriginal welfare officer at the prison. This was the first of two deaths within twenty-four hours in the Rockhampton Correctional Centre.

Additional Royal Commission Recommendations Breached

R7 Specific State/Territory Coroner for inquiries. (IR44)

R9 Stipendiary Magistrate or more senior person to be Coroner. (IR44)

R12 Coroner be required by law to investigate quality of custodial care prior to death. (IR46)

R13 Coroner to make recommendations to prevent further deaths. (IR44)

R92 Legislative enactment of the principle that imprisonment be a last resort.

R152f Guidelines for exchange of information between medical and prison services. (IR37)

R152g(iv) Protocols for the management of prisoners who are at risk of self-harm.

R152g(v) Protocols for the management of prisoners who are angry, aggressive or otherwise disturbed.

R152g(vi) Protocols for the management of prisoners suffering mental illness.

R154a Training of Prison Medical Services staff to ensure they understand Aboriginal health issues.

R165 Elimination/reduction of items with potential for self-harm.

R174 Aboriginal Welfare Workers in prisons.

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14QLD

Male 24, died on 3 April 1990
Rockhampton Prison, Queensland
Self-inflicted, Hanging

Coronial Inquiry K P Lynn at Rockhampton Coroner's Court

Finding handed on 2 November 1991

Finding

The cause of death was hanging.

Summing up

Circumstances of Death

The deceased hanged himself in his cell the night after another Aboriginal inmate was found hanged in the Etna Creek Prison (now Rockhampton Correctional Centre). The first death resulted in unrest and anger from some inmates, including the deceased. His file was already marked 'suicidal.'

Prison officers observed the deceased singing and playing his guitar with other inmates in the latter part of the evening. Although he spoke about his lack of fear of suicide, the Coroner found that other prisoners had no suspicions that the deceased would actually commit suicide.

The block officer had been told the deceased was unsettled and should be checked regularly. These instructions were not passed on to the relief, however, who took over at about 9.30pm. No further checks were then made for nearly two hours.

At around 11.10pm, during a head count, the deceased was seen in a sitting position, his back against the rear wall of the cell. His body was next to the toilet bowl with his heels and calves touching the ground and the rest of his body hanging suspended from a piece of white material attached to the lower centre louvre at the rear of cell. He had also cut his wrist, and there was a large pool of blood on the floor.

After obtaining the keys to the cell, officers undid the noose and checked the deceased for signs of life. Although at first it was thought there was a small pulse in the right wrist, further checks were unable to detect any vital signs. Ambulance officers and the GMO attended the deceased and he was found to be dead.

Issues

The Coroner stated that the correctional centre did not have a formulated plan for dealing with inmates suspected of being suicidal.

The Coroner found that the deceased's history of offences against prison rules and regulations showed he was an inmate who had difficulty coping with prison life. As well as a 12 month sentence for break and enter, the deceased had received a 3 month sentence, three days prior to his death, for damaging government property in a suicide attempt. He had been arrested for drunkenness, and knotted strips of blanket were discovered during a check of his police cell.

The Longreach District Officer submitted a report to Rockhampton Prison following this incident, stating that the deceased was a potential suicide risk.

A government medical officer (GMO) at Longreach later offered a contrary opinion, advising that there was very little chance of a repeat attempt. On admission to the Etna Creek facility, another GMO referred the deceased to a psychiatrist, believing 'he was more depressed than you would expect an inmate to be on admission. ' Following a brief examination, the psychiatrist found no significant risk of suicide, although he prescribed a relaxant medication three days later. A letter from the psychiatrist, received by the Prison after the death, stated that the deceased 'retained a tendency [to be a danger to himself] and should be monitored if his circumstances deteriorate'.

The deceased's file, the chief's log and the location board were marked suicidal but no oral or written instructions were given about additional monitoring or other procedures, such as removal of hanging points. After the suicide the previous night, the superintendent spoke collectively to the inmates and individually to the deceased, and asked another inmate to keep an eye on him. He also requested the block officer to keep a close watch on the deceased. There were 'no specific additional instructions given regarding the deceased, the superintendent being of the opinion that officers were already aware of the deceased's tendencies'.

The Coroner noted several deficiencies in prison procedure in his rider. Two hours elapsed between cell checks, although officers had expressed the opinion that half-hourly to hourly checks were appropriate depending on the level of concern about the inmate. Both the GMO and the psychiatrist stated that they made comments about monitoring the deceased that were not included in the inmate's medical records.

Recommendations

The Coroner made a number of recommendations in a rider forwarded to the Attorney General, including:

1. That 'a conference be held between medical and custodial staff to formulate a specific plan of action with respect to the supervision of each at risk inmate';

2. That 'specific instructions be formulated to cover exactly what supervision and action is progressively required in order that officers clearly understand what they should be doing by way of monitoring';

3. That if concern is felt there should be a practice of keeping an eye on the inmate, with hourly or half hourly checks progressing through to one-on-one supervision.

Royal Commission Recommendations

R123 Instructions on care of persons in custody to be known, understood, enforceable and publicly available.

R155 Training of prison officers to include Aboriginal health, information, risk assessment and appropriate emergency action to be taken. (IR28)

R152f Guidelines for exchange of information between medical and prison services.

R152g(iv) Protocols for care and management of Aboriginal prisoners who are at risk of self-harm.

Social Justice Commissioner

Comment

This death and the previous death raise questions which the Coroner did not address. Both prisoners had records of frequent breaches of discipline. As noted in relation to the previous death, the administrator of the Rockhampton Aboriginal Legal Service had told journalists at the time of the death that inmates at the prison were discontent and had reported 'intimidation, harassment and unfair disciplinary action from prison officers, including the denial of privileges for petty offences'. Again, the accuracy or otherwise of this claim should have been addressed.

The three month prison sentence for damaging a blanket in police cells in the course of a suicide attempt is indefensible. Charges should not have been laid at all, but to resort to imprisonment for such a minor offence, especially while the Royal Commission was proceeding, is extraordinary.

The Coroner emphasised the complete lack of any procedures to accompany the 'at risk' classification. It was found at the inquest months later that there was no evidence of procedures for suicidal inmates. The deaths had not provoked a consideration of procedures to reduce risks of similar incidents in the future. The Royal Commission Interim Report, which had been released at the time of the Inquest, declared that 'the dangers of placing emotionally disturbed... prisoners in isolation for whatever cause without a full measure of surveillance cannot be over-emphasised. The young appear particularly vulnerable [and] it is no longer acceptable to claim that close surveillance is not practicable. The means must be found'. 3

Additional Royal Commission Recommendations Breached

R7 Specific State/Territory Coroner for inquiries. (IR44)

R9 Stipendiary Magistrate or more senior person to be Coroner.(IR44)

R12 Legal requirement for Coroner to consider how the person was treated before death. (IR46)

R92 Legislation to ensure imprisonment is used as sanction of last resort. (IR1)

R124 Debriefing procedures to follow incidents to reduce future risks.

R164 Care in laying charges in cases of self-inflicted harm with preferably no charges laid.

R165 Elimination / reduction of items with potential for self-harm.

R173 Shared accommodation facilities.

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21QLD

Male 28, died on 17 October 1990
Mornington Island Watch-house, Townsville Hospital
Head injury

Coronial Inquiry Coroner Irvine Killeen,

at Mornington Island, Townsville and Brisbane

Finding handed down 20 November 1991.

Findings

The deceased died from raised intracranial pressure due to (or as a consequence of) traumatic brain damage. The failure by the various members of the Police Service or Aboriginal Police to adequately care for and supervise the deceased whilst in police custody did not constitute negligence to a criminal degree.

Summing Up

Circumstances of Death

The deceased was found lying unconscious beside the road by two Aboriginal community policemen on patrol. His condition, previous arrests for drunkenness and apparent lack of signs of serious injury led them to assume he was only affected by excessive alcohol consumption. Other prisoners gave evidence that they also thought the deceased was 'drunk and asleep'.

His condition was not noticed the following morning when the other prisoners were released. Later in the morning he was unable to be woken by an Aboriginal police aide. He was transferred to Townsville General Hospital where attempts to revive him were unsuccessful.

It was accepted that the injury had been caused by a blow or number of blows to the head inflicted by one or more of a named group of children when the deceased was lying drunk in the grass. No charges were laid. Further pathological evidence revealed a previous serious head injury probably inflicted some two weeks earlier, which would have predisposed the deceased to the fatality of the later attack.

Issues

Evidence tendered that the Aboriginal community policemen had handled the deceased roughly and caused the brain injury were denied by both. The delay in the medical examination and treatment of the deceased following the assault may have contributed to his death, but no person was found to have suspected injury requiring medical attention. The Coroner was particularly scathing in his criticism of the circumstances of death, and made a number of findings including:

That there was a failure on the part of all individuals on duty during the incarceration of the deceased at the police watch-house to properly perform their custodial duty and responsibility, and that none of them had any training to enable them to distinguish intoxification from more threatening conditions.

The conduct of police in leaving Aboriginal community police aides unsupervised and in charge of people in police custody was inappropriate. The turnover of Aboriginal Police Aides indicated a problem with their employment conditions.

That driving past the watch-house and observing the cells by shining the headlights through the front screen mesh was improper and inadequate and not in accordance with General Instructions and the cursory and fleeting inspections of prisoners were infrequent and not in accordance with instructions.

The arrest of the deceased was also found to be 'unlawful' as the community police aides have no authority under Council By-laws to make arrests on behalf of police.

The absence of means for prisoners to raise the alarm or contact police in emergencies was also raised, although no other prisoner noticed the condition of the deceased and he had been unconscious before his arrest. 4

Recommendations

The Coroner made recommendations relating to his findings including:

1. The Duty of Police Officers towards People in Custody

i. The Police Commissioner is to ensure by means of training or General Instruction that the Recommendations of the Royal Commission are conveyed to and are fully understood by all members of the Police Service.

ii. All police officers shall comply with the General Instructions regarding watch-house procedures.

iii. All Watch-house Keepers and Officers in Charge of small stations shall ensure strict adherence to the General Instructions regarding watch-house procedures.

iv. All police officers to be made fully aware of the duty of care owed to persons in police custody.

2. Appointment and Training of Aboriginal Policemen

i. It is to be acknowledged as important that Aboriginal Policemen be appointed to assist members of the Police service in policing Aboriginal communities.

ii. The Council, as employer of Aboriginal policemen, should increase the monetary or other benefits to Aboriginal Policemen as an incentive and inducement to attract and keep suitable persons as Aboriginal Policemen. An alternative is for the Police Service to employ or pay a retainer fee to such persons.

iii. An Aboriginal Policeman shall receive proper formal training prior to commencement of duty.

iv. An Aboriginal Policeman shall not be placed in charge of a police watch-house or left unsupervised excepting in emergency situations.

3. Arrest for Drunkenness

i. The Council should amend its by-laws as a matter of urgency to authorise Aboriginal Policemen to arrest or apprehend persons for drunkenness.

ii. All unconscious persons, through intoxification or otherwise, apprehended or found by Police shall be examined by a suitable trained medical person preferably a Doctor.

iii. The practice of the division or separation of the functions and operations of the members of the Police Service and the Aboriginal Policemen on Mornington Island should cease. It is more appropriate that an Aboriginal Policeman work alongside a member of the Police service particularly on community patrol.

iv. The State Government should consider, as a matter of urgency, implementation of legislation to decriminalise drunkenness.

4. Facilities for the Care of Drunken Persons

i. Although not a relevant factor in the death, the police watch-house does not provide a safe custodial environment. It is in a poor condition, is not conducive towards proper supervision or care of prisoners, it is isolated from the Police Station, it does not provide an alarm or means for a person in custody to contact the person in charge of the watch-house. The State Government should consider the immediate replacement of this watch-house.

ii. As most persons are arrested for drunkenness and placed in police custody for their own safety and protection, it is recommended that a diversionary facility be established on Mornington Island to accommodate, care for and treat persons affected by excessive alcohol consumption.

Royal Commission Recommendations Breached

IR34 Aboriginal police aides scheme be re-examined to ensure that role is not merely to assist police in everyday duties but to be a link between the Aboriginal community and police

R79 Abolition of the offence of public drunkenness. (IR3)

R80 Adequately funded custodial care to accompany abolition of this offence. (IR4)

R81 Statutory duty to consider and use alternatives to police detention of intoxicated persons. (IR5)

R1 Police and custodial authorities to recognise their legal duty of care to persons in their custody.

R123 Instructions on care of persons in custody to be known, understood, enforceable and publicly available.

R127a Readily available medical assistance in centres other than capital cities.

R127f(i) Rules for care and management of Aboriginal prisoners at risk because they are intoxicated. (IR15)

R133 Training of police officers to recognise those in distress or at risk. (IR14)

R135 People unconscious or not easily roused to be taken to a medical service, not a watch-house. (IR12)

R136 People found unconscious or not easily roused to have immediate medical care. (IR13)

R137 Police training and instructions to require checks of detainees; specified intervals between checks on the health and safety of detainees; monitoring/checking procedures (IR15).

R141 No-one to be detained without care and supervision.

R232 Urgent review of Queensland community police and the powers of community councils concerning them. (IR34)

Social Justice Commissioner

Comments

The post-death investigation was deficient in a number of respects. Police gave evidence by way of statements rather than records of interview. The police report was only made available to the solicitor for the next of kin hours before the inquest. Although described as a conscientious attempt, it did not investigate whether there was compliance with general instructions in the police manual, whether there was a suitable discharge of the duty of care, or whether there were systemic problems in police procedures which should be rectified to prevent further deaths.

The standard and quality of policing on Mornington Island showed profound deficiencies. The Human Rights and Equal Opportunity Commission's Report on Mornington Island recently followed-up problems with the administration of justice on the Island. The Watch-house has been replaced, but: (a) the Queensland Police Service failed to consult with the community about the new watch-house; (b) there is a failure to separate clearly the court function from the police function in the new police complex; and (c) the expense ($2.8M) and size of the new complex is an inappropriate response to the needs of the community, given the lack of a sobering-up centre on the Island. There continues to be a failure to ensure that Aboriginal communities have formal and ongoing participation in the selection of police officers in their communities. 5

The need is apparent for screening procedures in order to assess the physical and mental health of detainees before they are placed in cells. If such a procedure were in place (see Recommendations 125), it is likely the deceased would not have been placed in a cell.

Other Royal Commission Recommendations breached

R7 Specific State/Territory Coroner for inquiries. (IR44)

R36 Police investigations should be structured to provide a sound evidentiary base for the coroner.

R125 Screening form to be routine part of reception into custody and to be evaluated.

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22QLD

Male 17, died on 12 January 1991
Lotus Glen Prison, Qld
Self-inflicted, Hanging

Coronial Inquiry Coroner H T Spicer

Finding

The cause of death was hanging, with no evidence of criminality against any person.

Summing up

Circumstances of Death

The deceased was HIV positive, and as a result was placed in segregation at Lotus Glen Prison in compliance with Correctional Services policy and directives from the Commission's Director of Medical Services.

On 12 January 1991 the deceased was found hanging in his cell by staff delivering the evening meal at approximately 5.50pm.

Issues

The deceased, from Palm Island, had been diagnosed as HIV positive at sixteen, and was the first Aboriginal prisoner in Queensland with the virus. On July 25, 1990 he was found guilty before Judge Wylie in Townsville District Court of wilful exposure, two charges of assaulting police, wilful damage to property and break and enter. The circumstances of the offence included smearing his excrement in the face of a police officer. He made an early plea of guilty, had no previous convictions and expressed remorse, but was sentenced to nearly three years in prison. He was only expected to live for two years. Deterrence of the threat of AIDS in the course of criminal activity was held to outweigh the personal circumstances of the offender in sentencing.

In August 1990, a letter was signed by the nursing staff and sent to the Manager of Operations outlining concerns for the physical and mental well-being of the deceased and another prisoner in isolation. In response, visits by an Aboriginal Official Prison Visitor and regular trips to Cairns to see an AIDS counsellor were arranged.

The Coroner found that the main contributing factors leading up to the death appeared to be the fact he was HIV positive; his isolation; his sentence and loss of appeal against sentence; the rejection of his application for a pardon; the rejection of his application for parole; the inadequacy of family support; and, the termination of counselling by a volunteer counsellor with the Queensland AIDS Council who was also HIV positive.

A directive from an officer of the Queensland Health Department, who was apparently acting on advice from an Aboriginal person, had the effect of cancelling the visits from the counsellor. This 'misunderstanding' caused considerable distress to the deceased.

It appears the deceased was fairly well provided for in terms of material comforts and access to counsellors and prison staff. However 'his conditions lent towards isolation from 6pm until morning' (other prisoners could mix with each other until 9.30pm).

The last visit by any member of the family was some five months before his death. His mother could only afford to make the 350km trip to visit the deceased once in the year prior to his death. That trip was paid for by a newspaper.

Recommendations

1. That on reception at a Correctional Centre, there be an immediate in-depth psychiatric and physiological assessment of the person admitted, particularly in cases of:

(a) AIDS sufferers

(b) Suicide risks

(c) Aboriginal cultural backgrounds.

It is extremely important in relation to Aboriginal people that a detailed history of family background be obtained including cultural needs and geographical position of the relatives.

2. That Aboriginal support groups assist in maintaining close family relationships, including funding and transport, especially where the inmate is geographically separated by distance from family and relatives.

3. That ongoing tuition be given to correctional staff, especially to address the problems of inmates with AIDS and inmates of Aboriginal culture.

4. That in situations such as arose in this case [and] especially in AIDS cases, [that] liaison be established and maintained amongst all parties concerned.

Royal Commission Recommendations

R152g(vii) Protocols for specific action to be taken in the case of serious medical conditions.

R154a Training of Prison Medical Services staff to ensure they understand Aboriginal health issues. (IR28)

R155 Training of prison officers to include Aboriginal health, information, risk assessment and appropriate emergency action. (IR28)

R168 Prisoner to be incarcerated near family.

R169 Financial assistance for visits where a prisoner is not incarcerated near family.

Social Justice Commissioner

Comment

The Coroner's recommendations show a degree of insight and sensitivity to the needs of Aboriginal inmates, particularly those in the deceased's situation. It is particularly welcoming to see issues such as geographical location of family and Aboriginal culture being included in admission assessments. His recommendation that 'Aboriginal support groups assist in maintaining' family ties should be read as recommending adequate funding and resources to carry out this role.

The case begs the question of why police engaged with the deceased other than with the care needed when any person is displaying signs of mental illness. He was obviously disturbed. He had smeared excrement on himself and was masturbating on a veranda when police approached him. He was convicted of wilful exposure, two charges of assaulting police, wilful damage to property and break and enter. The circumstances of the offence included smearing some of the excrement already on his body in the face of a police officer - not a premeditated act. He made an early plea of guilty, had no previous convictions and expressed remorse, but was sentenced to nearly three years in prison. He was only expected to live for two years. His condition placed him under great mental stress. A punishment more humane than effective life imprisonment could have been arranged for the dying juvenile. The principle of imprisonment as a last resort (Royal Commission recommendation 92) should have applied.

Recommendation 173, that Aboriginal prisoners should not be put in isolation or segregated from other prisoners, is also relevant. Prison officials informed the Coroner that other prisoners would not be disposed to share with the deceased. An Aboriginal woman who visited the prison shortly after the death reported that inmates told her they would have had no problems being housed with the deceased.

In refusing to allow the appeal against the severity of the sentence, McPherson J of the Queensland Court of Appeal referred to the deceased's condition with what the authors to the predecessor to this study referred to as 'callous and offensive brevity': 6

We understand that he has also been informed at the beginning of 1990 that he had the HIV condition and that he will die from it. He is a person of low intelligence.

Additional Royal Commission Recommendations Breached

R7 Specific State/Territory Coroner for inquiries. (IR44)

R92 Imprisonment as a last resort. (IR1)

R96 Training of judicial and court officers in Aboriginal society, history and culture.

R181 Segregation and isolation of Aboriginal prisoners to be avoided. Minimum standards for segregation including fresh air, lighting, daily exercise, adequate clothing and heating, adequate food, water and sanitation facilities and some access to visitors.

R183 Commitment and assistance to operation of Aboriginal support groups within institutions.

R242 Police to use cautions rather than arrest, or summons or attendance notice, preferably with guardian present.

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25QLD

Male 34, died on 2 May 1991
Rockhampton Police Watch-house, Qld
Epilepsy

Coronial Inquiry Ivan Smith SM at Rockhampton Coroner's Court

Finding handed down 15 January 1992

Finding

The cause of death was epilepsy due to or as a consequence of alcoholism.

Summing up

Circumstances of Death

The deceased had been arrested for an unpaid fine and for an obscene language charge which, as noted by the Coroner, had a default period of two days imprisonment for the sixty dollar fine. He was placed in a cell at approximately 9:30am on 1 May 1991. He had apparently been involved in a fight. He had a noticeable facial injury. The deceased apparently refused medical assistance offered by police.

The deceased was found dead almost 24 hours later. Rigor mortis had set in. He had not risen out of bed in that time.

Issues

The Coroner was highly critical of the claim by the Police Service that relevant recommendations had been implemented, saying that 'the use of the word "implemented" seems entirely inappropriate as I understand the meaning of the word. The facts are that, at least in Rockhampton Watch-house, a number of those recommendations have not been implemented'.

The Coroner found that the deceased should have been required to undergo a medical assessment on admission, particularly when it was known that he suffered from epilepsy and alcoholism, had a facial injury and was sick in the cell. He found that the death highlighted and emphasised the current deficiencies in the present watch-house system and the shortcomings and inadequacies of the present standing orders. The Coroner found that the deceased had been checked regularly by glancing through the cell door.

Recommendations

1. That a copy of this decision and recommendations go to the Assistant Commissioner, Rockhampton Police Region.

2. When it is apparent that a detainee is injured, particularly a possible serious head or facial injury, a medical practitioner should be made available to assess the nature and extent of the injury whether the detainee consents to such an examination or not.

3. Where it is apparent that a detainee suffers from epilepsy or similar illness, or a combination of alcoholism and epilepsy or a similar illness, whether or not on medication, such person shall not be detained overnight or for any period during the day in excess of two hours without there being a medical assessment of risk.

4. That the standing orders at Rockhampton Watch-house should be totally revised and urgently updated to include the recommendations of the Royal Commission.

5. That police officers, especially those who work in the watch-house, are made thoroughly aware of the revised and updated standing orders rather than simply shown a list of such orders on the watch-house wall on commencing duty.

6. That, where possible, young and very inexperienced officers should not be rostered on the night shift at the watch-house, a more dangerous time for certain detainees calling for a certain maturity, common sense and experience.

Royal Commission Recommendations Breached

R122 Police and custodial authorities to recognise duty of care.

R123 Instructions on care of persons in custody to be known, understood, enforceable and publicly available.

R125 Screening form to be routine part of reception into custody and to be evaluated.

R127a Regular medical presence in watch-houses in capital cities and other major centres.

R127f(i) Rules for care and management of Aboriginal prisoners at risk because they are intoxicated.

R127f(ii) Rules for care and management of Aboriginal prisoners at risk because they suffer illnesses.

R131 Police recording of information affecting risk.

R133 Training of police officers to recognise those in distress or at risk.

R138 Police instructions to require recording of information relevant to well-being of detainees.

R161 Instructions to seek immediate medical care if doubts about prisoner's condition.

Social Justice Commissioner

Comment

Although the Coroner appeared to accept police statements that the deceased had been checked regularly by police looking through the cell door, the findings are not convincing. Rigor mortis had set in by the morning of 2 May. That he had not arisen out of bed in almost 24 hours casts doubt on statements that checks took place. If checks took place, they were clearly not adequate for a person in his condition. There was no reference in the findings to written records of the checks.

The Coroner expressly stated that the majority of custodial health and safety recommendations relevant to this death were not implemented at the Rockhampton Watch-house. Unfortunately, the findings did not contain enough information to determine the full extent of the breaches.

The Coroner did not comment on other significant aspects of the case. The deceased was arrested on a warrant for a charge of obscene language, a trivial offence specifically singled out for criticism by the Royal Commission. The Coroner should have examined the lawfulness of this arrest as the charge had not yet been proven in court (Recommendation 35c). As there is no indication that he was brought before a magistrate during the day of 1 May, it appears that the deceased was to serve an automatic two day period of imprisonment for an outstanding warrant for an obscene language charge,

Police demonstrated a lack of understanding of what a duty of care entails. The deceased had a known history of epilepsy and drunkenness and an obvious facial injury, and yet police did not realise that they, by deciding to arrest and effectively exclude other avenues of medical assistance, assumed a common law duty of care (as well as any statutory duty on them to care for prisoners).

Other Royal Commission Recommendations Breached

R7 Specific State/Territory Coroner for inquiries.

R12 Legal requirement for Coroner to consider how the person was treated before death.

R13 Coroner to recommend ways to prevent further deaths.

R35 Police investigations should inquire into the arrest or apprehension, lawfulness of custody.

R86 Offensive language during police initiated action not to be basis for arrest and charge.

R87 Police to apply arrest as a final sanction.

R92 Imprisonment as a last resort.

R121 Imprisonment not be automatically imposed for default on fine payments. Alternative sanctions be considered, and a statutory duty to consider capacity to pay.

R137 Training of police to ensure regular, careful and thorough checks of all detainees, with more regular checks for detainees at risk.

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32QLD

Female 44, died on 14 November 1991
Townsville Hospital, ex Palm Island Watch-house, Qld
Head Injury

Coronial Inquiry Coroner Fisher

Finding handed down 2 November 1994.

Finding

Having remained unconscious since 5 October 1991, the deceased suffered respiratory failure as a result of a cerebral necrosis as a consequence of head injury on 14 November 1991. No person is committed for trial for an offence in relation to this death.

Summing up

Circumstances of Death

The deceased was arrested on 4 October 1991 after police were called to an argument at her home. The Coroner stated a knife and a small child were involved. On arrival, it was established that the deceased was very intoxicated. After being asked by the other occupants of the house to leave and refusing, the deceased was physically conveyed outside the house and placed near the rear of the police vehicle parked outside. She was then arrested for being found drunk in a public place.

The deceased was taken to the watch-house. The Coroner found that she was awake but drunk. Periodic checks were made during the course of the shift and she was found to be asleep and snoring. The following morning the deceased was observed frothing at the mouth by a police officer checking on overnight prisoners. Attempts were made to wake her, but were unsuccessful. She was then conveyed to the Palm Island Hospital and found by the medical superintendent to be comatose.

The deceased was conveyed to Townsville General Hospital where she was diagnosed as having had a large left frontoparietal subdural haematoma. An operation was performed to remove the haematoma, but the deceased remained in a comatose state until her death on 14 November 1991.

Issues

There had been a struggle in the course of the arrest. The Coroner reported that no injuries of any kind were noted on the deceased, either by the police or by medical authorities.

The Coroner noted that the creation of detoxification centres, which are being or are to be established, will significantly assist what is said to be a very difficult, if not impossible, task in relation to the assessment of the condition of drunken persons.

Recommendations

1. That extra copies of form 4 be prepared for inclusion with any samples forwarded for pathological examination. 7

2. A copy of this transcript of proceedings be provided to the Commissioner of Police for examination and further dissemination of any information or instructions, as he may deem necessary, regarding apprehension and care of drunken persons.

Royal Commission Recommendations

R133 Training of police officers to recognise those in distress or a risk.

Social Justice Commissioner

Comment

The Inquest was not completed until some three years after the death. Witnesses had made statements to the Townsville Legal Service that the deceased was 'carried and thrown' by two policemen into the back of the police vehicle. These were rejected by the Coroner, who listed the cause of death as cerebral necrosis in his findings without any explanation of the head injury which the post mortem examination listed as a cause of death.

The legality of the arrest is questionable, although the Coroner made no comment. The police had conveyed the deceased from a private home and charged her with 'being drunk in a public place'.

The coronial findings did not adequately address the issue of the resistance to police by the deceased when she was physically restrained and taken out to stand beside the police van. The Coroner relied on the evidence of the police and medical staff for the finding that there was no mistreatment of the deceased. The evidence seems to have come solely from the Police Report. The allegation was aimed at the police. The deceased remained in a coma for nearly a month after the arrest. Any injuries caused may have had time to heal before an autopsy was carried out. Medical staff may not have been aware of the allegations. Part of the function of an Inquest is to dispel public suspicion of misconduct. The Coroner failed to do so in this case.

This investigation highlights the problems associated with the ad hoc nature of the Coronial system in Queensland. Lengthy delays result from co-ordination required between police investigators, forensic pathologists and Coronial staff. A centralised system with specialist staff, as recommended by the Royal Commission, would alleviate some of the problems. Legislation should be enacted, urgently, for a centralised and independent investigation process to bring Queensland into line with other states.

Additional Royal Commission Recommendations Breached

R7 Specific State/Territory Coroner for inquiries.

R8 Development of specific rules for inquiries and inquests.

R12 Legal requirement for Coroner to consider how the person was treated before death.

R13 Coroner to recommend ways to prevent further deaths.

R35 Police investigations should: be approached on the basis that the death may be a homicide; inquire into the arrest or apprehension, lawfulness of custody and treatment and supervision of the deceased; and, thoroughly examine the scene of death and forensic exhibits.

R60 Police services to eliminate rough treatment or abuse of Aboriginal prisoners.

R79 Abolition of offence of public drunkenness.

R80 Adequately funded facilities for intoxicated persons to accompany abolition of this offence.

R81 Statutory duty to consider and use alternatives to police detention of intoxicated persons.

R125 Completion of a screening form prior to placement in a cell.

R135 Intoxicated or semi-rousable people to be given medical attention, not conveyed to police cells.

R136 People found unconscious or not easily roused to have immediate medical care.

R137 More frequent checks of prisoners at risk.

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34QLD

Male 17, died on 22 December 1991
Sir David Longlands Prison, Qld
Self-inflicted, Hanging

Coronial Inquiry Coroner Gary Casey SM at the Brisbane Coroner's Court

Finding handed down 4 June 1993

Findings

The Coroner found that the deceased died in cell 3, unit 2C of the Sir David Longlands Correctional Centre of hanging. There was no evidence of a criminal nature that may be imputed to any person, and evidence adduced supports the inevitable conclusion that the deceased was a potential risk of committing suicide.

Summing Up

Circumstances of Death

The deceased was sentenced to six months imprisonment for motor vehicle offences in August 1991. During this term he received three additional six month sentences for offences committed prior to his incarceration. Although a juvenile, he asked to be treated as an adult prisoner. He was moved to Boggo Road, and when it closed, to Sir David Longlands Prison.

His medical history form at Boggo Road indicated that he had previously attempted suicide. No procedures were put in place as a result. He was withdrawing from amphetamine abuse, had migraines and had lost weight. His mother had expressed concern to corrections employees about the drugs he was receiving in prison to replace his dependancy (for example, valium, neulactil). He had failed to recognise her during a visit, and she described him as heavily sedated, his face swollen and puffy.

The senior psychologist at the prison described the deceased as severely depressed, but refused his request for anger management counselling. Concerned by his suicidal tendencies, his Unit Manager referred him to the Nursing Manager in September. His dose of valium was increased as a result. He was then given diazepam after partially destroying his cell, and a valium after complaining of claustrophobia in October.

On December 11 the deceased cut both his wrists after a disagreement with his girlfriend. He was returned to his cell after 24 hours observation. On December 16 and 17 he was locked in his cell for 48 hours, during which time he again destroyed the cell. A doctor saw him on December 17 and prescribed medication for his 'acutely disturbed' state. On December 18 he was moved from the youthful offender unit into the mainstream adult prison.

The deceased's girlfriend had ended their relationship on night of his death. Corrective Services personnel notified a nurse of emotional disturbance. He was given mogadon and received verbal re-assurance from the nurse and another adult inmate. He was then locked in for the night in accordance with routine prison practice.

He was checked cursorily by officers at lock down, around 8:30pm, and not checked until around 10.50pm when his body was found hanging by a bed sheet suspended from the bar of the window above the cell door Despite resuscitation attempts by Queensland Ambulance Service personnel, the deceased failed to respond and life was subsequently pronounced extinct at 11:45pm.

Issues

The Coroner noted that the deceased's history of suicide attempts and self-harm was on record at the prison, and that no action was taken as a result. The deceased was also upset at the prospect of spending Christmas in prison after receiving an additional sentence in November. The findings also noted the effect of the two day lock down of the prison soon after he had cut his wrists, reportedly because high security prisoners had to be transferred to a facility one kilometre away. It was noted that the move into the adult prison was a contributing factor.

The Coroner noted that the mogadon given to the deceased on the night of his death was not an appropriate or effective medication for his recognised severe depression.

The findings contain criticism of the inadequate recording of information at all levels within the Correctional Centre, and inadequate awareness by staff of administrative requirements and management procedures.

Recommendations

The Coroner recommended that resources be made available so that adequate health services, particularly psychiatric services, be provided and maintained within institutions and additional qualified personnel and trained ancillary staff be recruited.

Anomalies in the continuity of services and the paucity of thorough and contemporaneous records involving the treatment, counselling and welfare of prisoners should be addressed as a priority.

There need to be adequate administrative directives and proper safeguards to ensure their fulfilment in respect of the following matters:

1. The proper and adequate recording of information regarding the welfare of prisoners, particularly younger prisoners with known self-injurious, irrational or disturbed behaviour;

2. The dissemination of information gathered to all levels of personnel within the centre;

3. The adequate exchange of information between staff members moving from different sections (or units) within the centre;

4. The attendance of all personnel at properly authenticated courses for the prevention of suicide, which should include methods of detection of prisoners considered to be potential suicide risks;

5. The attendance of all staff at approved courses in first aid and resuscitation techniques, which should include the requirement that a proficient standard be attained in the use and maintenance of relevant equipment employed;

6. All personnel be required to read and familiarise him/herself with the Recommendations of the Royal Commission into Aboriginal Deaths in Custody;

7. In the development of a plan of Management for younger offenders, designed to improve their well-being and for the better utilisation of their time, that input be sought from custodial officers (Aboriginal and non-Aboriginal) within the centre who have a proven genuine interest in schemes for the betterment of such offenders, and with a proven empathy with individual/s.

That a structured plan be developed to ensure expeditious access to prisoners and their treatment in times of emergency.

That the Police Service issue a directive to preserve clothing worn by a deceased person at the time of his/her death.

Royal Commission Recommendations Breached

R150 Health care should be of equivalent standard as general community.

R151 Referral of Aboriginal prisoners/detainees for psychiatric care.

R152a Review of health services provided to Aboriginal detainees with AMS and other bodies to consider standard of health services available.

R152f Guidelines for exchange of information between medical and prison services.

R152g(iv) Protocols for care and management of prisoners who have a history of self-harm.

R152g(v) Protocols for care and management of prisoners who are angry and aggressive.

R152g(vi) Protocols for the management of prisoners suffer mental illness.

R152g(viii) Protocols for care and management of Aboriginal prisoners on medication.

R153a Ongoing review of prison medical services.

R154a Prison medical services staff to be trained in Aboriginal health, including history, culture and lifestyle; efforts to employ Aboriginal people in prison health services.

R155 Training of prison officers to include Aboriginal health, information, risk assessment and appropriate emergency action to be taken.

R158 The first response of police or prison officers to a person apparently dead should be to attempt resuscitation.

R159 Availability of safe, effective resuscitation equipment and trained staff in all prisons and watch-houses.

R161 Instructions to seek immediate medical care if doubts about prisoner's condition.

R181 Segregation and isolation of Aboriginal prisoners to be avoided. Minimum standards for segregation including fresh air, lighting, daily exercise, adequate clothing and heating, adequate food, water and sanitation facilities and some access to visitors.

Social Justice Commissioner

Comment

The death in an adult prison of a juvenile with mental health problems reveals the continuing need for comprehensive improvements in the standard of custodial health and safety. The Coroner made useful and important recommendations. The Royal Commission recommended that governments publish annual reports containing coronial recommendations and findings so that the coronial process can contribute to the development of safer custodial conditions. There is probably no jurisdiction with more avoidable deaths than Queensland.

The evidence indicated that the visiting psychiatrist paid an insufficient degree of attention to the deceased's condition. The psychiatrist was semi-retired and failed to put a psychiatric report on file in three visits. No psychiatrist saw the deceased after he cut his wrists, as this psychiatrist was on leave and there was no replacement. Counsel for the family submitted the transcript of cross examination of the psychiatrist, which he claimed revealed a disgraceful standard of mental health care, to the Health Minister.

Psychiatric services must be of a sufficient standard to detect prisoners at risk of suicide and provide appropriate care. It is in the interests of the community that prisoners with mental health problems receive adequate attention before they are released. It is inhumane not to provide adequate psychiatric services in the harsh environment of a prison.

The Coroner also raised problems in the notification and counselling of the family.

Additional Royal Commission Recommendations Breached

R7 Specific State/Territory Coroner for inquiries.

R8 Development of specific rules for inquiries and inquests.

R95 Where motor vehicle offences are a major factor in imprisonment, programs to be consultatively developed to reduce incidence.

R165 Elimination/reduction of items with potential for self-harm.

R167 Juvenile Detention Centres be reviewed to ensure compliance with custodial health and safety recommendations.

R328 Resources to translate Standard Guidelines for Corrections in Australia into practice.

R329 Legislation to to embody Standard Guidelines and prisoners rights, as in Victoria.

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38QLD

Female 58, died on 25 May 1992
Brisbane City Watch-house, Qld
Natural Causes, heart attack

Coronial Inquiry Coroner Gary Casey

Finding handed down on 28 May 1993

Finding

The cause of death was (1) (a) acute cardial infarction due to, or as a consequence of, (b) coronary athrosclerosis; and (2) chronic alcoholism.

Summing Up

Circumstances of death

At approximately 1:30pm on 25 May 1992 two police officers from Woollongabba Police Station attended at 22 O'Connell St, West End in response to a call from the occupants of one of the flats. The police assumed the deceased was intoxicated. The Coroner found she was incapable of walking unassisted or communicating spontaneously. She was conveyed to Brisbane City Watch-house with some of her personal belongings and charged with drunkenness.

The Officer-in-Charge of the watch-house contacted Murri Watch, a community based care organisation, and told a worker that the deceased was at the watch-house and intoxicated.

Approximately two and a half hours later, at around 3:55pm, police noticed she was unconscious. Resuscitation was attempted. The Queensland Ambulance Service was contacted and the deceased was conveyed to Royal Brisbane Hospital, arriving at about 4.30pm. Further attempts to revive her were unsuccessful. She was certified dead at 5:05pm.

Issues

The deceased had frequently been arrested for drunkenness and police assumed she was intoxicated. However, a post mortem conducted the following day revealed that there were no traces of alcohol in her body. It also revealed that the deceased had suffered the heart attack which ultimately killed her some 12-24 hours prior to her death, before police arrived at the watch-house.

The questions that arise include:

a. whether the inference that the deceased was intoxicated was reasonable;

b. did the officers act unlawfully or improperly by removing the deceased from private premises to arrest her with public drunkenness under section 81 of the Liquor Act 1912?

c. whether the Watch-house Keeper properly exercised his responsibility in accepting the charge of drunkenness against the deceased and detaining her in the watch-house pending anticipated arrangements for her release into the custody of Murri Watch;

d. after the deceased was placed in cell number 11, were the actions of watch-house staff and prevailing watch-house conditions, procedures and staff training of a sufficient standard to properly address the situation of her incarceration? The areas of concern were prisoner inspections; first aid training, including the use of oxy viva equipment; and the information given to ambulance officers;

e. was the investigation of a sufficient standard to provide a thorough and impartial evidentiary base for the purposes of: (i) a coronial inquest into the case and circumstances of death; and (ii) establishing whether any inaction or failure by any police officer to provide due care or supervision, other than in a criminal sense, caused or contributed to the death.

Recommendations

The Coroner made the following recommendations:

1. While it remains possible for a person to be detained in police custody for an offence of being drunk in a public place, the inherent difficulties confronting police officers of distinguishing between drunkenness and other non-related medical conditions to determine whether a medical risk exists are exemplified by the circumstances associated with the instant death. It is impracticable for the responsibility for making medical assessments of persons in custody to be entrusted to unqualified non-medically trained personnel. Adequate administrative initiatives be implemented as a matter of priority to remove what I perceive to be an unfair and unrealistic onus on Police Service personnel, particularly those employed in the role of Watch-house Keeper.

2. The proposed Queensland Police Service Custody Manual which makes provision for implementation of the various responses to recommendations 127, 131, 132, 133, 135, 136, 138, 145, 159, 160, 161 and 223(b) of the Royal Commission into Aboriginal Deaths in Custody be adopted without avoidable delay. The suggested recommendations are complementary to other guidelines currently followed by police.

3. In so far as giving effect to the principles of recommendations 135 and 136, provisions be made to alert police personnel to those detainees, who although apparently conscious, have difficulty for no obvious acceptable cause, in articulating his or her thoughts or verbal responses.

Royal Commission Recommendations Breached

R127a Regular medical presence in watch-houses in capital cities and other major centres

R127f(i) Rules for care and management of Aboriginal persons who are intoxicated.

R132 Information exchange at change of shifts; written checklist for handover at change of shift; need for proper form for handover at change of shift.

R133 Training of police officers to recognise those in distress or a risk; content of this training; advice and assistance of AHS and ALS in design and delivery of such training.

R135 People unconscious or not easily roused to be taken to a medical service, not a watch-house.

R136 People found unconscious or not easily roused to have immediate medical care.

R138 Police instructions to require recording of information relevant to well-being of detainees.

R145 Aboriginal cell visitor schemes or similar in police watch-houses; Aboriginal community management (with appropriate funding); scheme not to reduce duty of care owed to detainees.

R159 Availability of safe, effective resuscitation equipment and trained staff in all prisons and watch-houses.

R160 Basic training for all police and prison officers in revival techniques.

R161 Instructions to seek immediate medical care if doubts arise about a prisoner's condition.

R223b Negotiated protocols for protective custody by virtue of intoxication.

Social Justice Commissioner

Comment

The coronial inquest was totally inadequate as the only public record of the investigation into the circumstances of the death. It does not serve the public interest in dispelling suspicions about the death. The conduct of the police was not scrutinised by the Coroner. The twelve police officers invoked the privilege against self-incrimination and declined to give evidence to the Inquest on advice from counsel.

They answered questions after the inquest when directed by a senior officer to do so. A journalist posed the question at the time 'If an elderly non-Aboriginal woman was seen in a distressed state, would it be assumed that she was drunk and thrown into prison?' 8 The case was referred to the Queensland Criminal Justice Commission for inquiry into the police conduct. Unfortunately, these investigations are not public. The basic findings of that inquiry are set out below.

The case obviously raises the inappropriateness of the criminal penalty for public drunkenness. The Royal Commission recommended police monitoring to ensure that intoxicated persons are not inappropriately held in protective custody despite the decriminalisation of public drunkenness (R85). This case illustrates the importance of monitoring in jurisdictions where public drunkenness is still a criminal offence.

The investigation by the Criminal Justice Commission was even-handed and complete, in contrast with the incomplete nature of the investigation by the Coroner, particularly the finding that there was no police impropriety despite hearing no evidence from police officers involved. Points not included in the Criminal Justice Commission investigation appear in italics in the summary below in italics.

Criminal Justice Commission

The Inference that the Deceased was Intoxicated

The Criminal Justice Commission investigation found that there was no basis for charges to be laid against the arresting officers, although investigators rejected their claim of noticeable odours of alcohol. The inference of intoxication was reasonable given the slow and slurred deliberate response to questioning, the inability to stand, the difficulty in focussing, the absence of signs of discomfort, and the fact that the residents of the flat were of the same opinion.

The Appropriateness of the Arrest

The investigation found that arrest was preferable and sensitive as the deceased was incapable of looking after herself. The investigator doubted that the officer had checked to see if there were other Aboriginal people in Musgrave Park who could have taken care of the deceased. General Instruction 10.12 of the Custody Manual was noted. It requires that persons being removed from premises be left absolutely free as soon as the street or public road is reached if they are not engaged in criminal conduct.

The Duties and Behaviour of the Watch-house Keeper

The behaviour of the Watch-house Keeper was scrutinised. The duty was to determine the propriety of the charge, and the condition of the deceased. He was found to have formed a preliminary view that the deceased was unconscious, and not appropriate for detention.

The evidence of consciousness was described as 'at best, inconsistent'. The Watch-house keeper changed his view that the deceased was not conscious on hearing of the deceased's behaviour at 22 O'Connell St (she had acknowledged her name); on hearing that examination by officers trained in first aid did not reveal that the deceased was in distress; on hearing the general view in the Watch-house on the night, expressed by persons experienced in dealing with drunks, that she was affected by alcohol; and on hearing of her history of detention for drunkenness. He considered that General Instructions 9.495 and 9.497 did not require him to seek medical attention, and the Inspector shared this view. The ambiguous directives were unsatisfactory. They breach Royal Commission recommendations 137 and 161, that medical attention be sought if doubts arise as to a detainee's condition. A directive was issued two days later that a government medical officer should be contacted if a detainee was unable to respond to questions about health, etc.

Murri Watch was contacted and apparently told the deceased had soiled herself. The representative responded that he would let her sleep it off and pick her up in a few hours. Watch-house procedures for recording notification of Murri Watch, and recording their response, were not complied with. Few details were given to Murri Watch, breaching previously agreed protocols. The investigator specified that details should have included her inability to answer questions about her health; the lack of a detectable odour of alcohol; her impaired consciousness; her inability to stand, requiring her to be carried; the fact that she not violent or aggressive; the arrangements made to clean up faeces; and the lack of any medical examination. The Murri Watch representative could not drive the only available vehicle, and stated that other members were not available when paged.

Custodial Care

The Criminal Justice Commission stated that on the medical evidence the deceased would have been unlikely to survive regardless of whether the procedures referred to below were followed in this particular case. Of course, the deceased may have survived if she had been taken to a hospital or been given medical attention when it first became clear that she was semi-conscious, in accordance with recommendations 137 and 161 of the Royal Commission.

First, the quality of inspections. Inspections, mainly from the door rather than physical checks, at twenty minute intervals were found to be adequate. Royal Commission recommendation 137d called for inspections more frequently than every 15 minutes in the first two hours if there were doubts about a detainee's condition. An officer observed at 3:30pm that the deceased was not in very good condition, although she 'appeared coherent'. There was a five minute delay before the officer responsible for her care attended and observed that she had no pulse. The CJC responded with recommendation 4.

Second, the attempt at resuscitation. Resuscitation was commenced at about 4:00pm by the officer with first aid qualifications, who was unsuccessful in operating oxy-viva. The next day the quipment was found to be operational.

There was no guarantee that any officer on a given shift would be qualified in first aid, as staff were generally not permanent but drawn from the City Station on a daily basis. The investigator noted that permanent staff had since been appointed, and that a new Police Custody manual and Custody Awareness Training Package would improve training in early detection of risk. The investigator made recommendation 5 in response to first aid issues.

Third, the issue of communication with ambulance personnel. The officer who found the deceased without a pulse at 3:55pm and called the ambulance only revealed one of the symptoms - difficulty in breathing - and the ambulance service attended the deceased with only oxy viva equipment and a drug kit. After the 4:00pm examination by a police officer trained in first aid revealed the deceased's cardiac arrest condition, a heart monitor was brought from the ambulance. If they had been properly notified, the ambulance officers would have brought the heart monitor immediately. The investigator accordingly made recommendation 6.

The Adequacy of the Investigation as a Basis for a Coronial Inquest

A Commissioner's circular required that the scope of the investigation should reflect Royal Commission recommendations 12, 13, 18, 35 and 36. The investigation did not do so up to the time the investigation was taken over by the Criminal Justice Commission. Police investigators appointed on the day of the death did not interview police involved, but merely requested that they make statements. In a preliminary report made the day after the death an investigator concluded that there was no police impropriety, that the death was unforeseeable and that procedures had been followed. Two days later, when the officer discovered that the autopsy revealed the deceased had not been intoxicated, further statements were gathered. Although the arresting officers interviewed maintained they did not collaborate in preparing statements, the accounts in their statements of a conversation between one of the officers and the deceased were identical.

One investigator merely recommended that assembly instructions appear under the lid of the oxy viva equipment. The other investigator recognised more fundamental issues, that: a prisoner who cannot be bailed and who cannot answer medical questions must be examined by a doctor; and a further training program is required, immediately, to ensure that all Senior Sergeants or persons acting in those positions are trained in the efficient, safe use of the oxy viva.

The CJC investigator inferred that the investigating police officer was worried because the post mortem report revealed deficiencies in his preliminary report, and that he amended it to include indicia of drunkenness (the odour of alcohol and details of a conversation with the deceased corroborating evidence of consciousness). The CJC criticised the making of assumptions and the acceptance at face value, or with limited inquiry of accounts, of the circumstances of the death. The investigator stated that immediately after an incident, the police investigators should require officers involved to independently make notes in official police notebooks, and that this should be followed by a tape recorded interview.

The investigator noted that Chapter 11 of the new Police Custody Manual merely requires that investigating officers 'obtain statements from all witnesses' without specifying a procedure or standard of completeness.

The Adequacy of the Coronial Inquest

Section 24 of the Queensland Coroners Act only involves consideration of criminal responsibility arising out of the immediate cause of death, not other deficiencies which might have contributed to the death, and does not assign formal recognition to recommendations by coroners. Action in response remains discretionary. It is especially difficult to have faith in the finding by the Coroner that impropriety was involved without the police involved being interviewed.

Criminal Justice Commission Recommendations

1. One officer be corrected under the Police Service Administration Act for procedural breaches with respect to the Murri Watch Cell Visitors scheme (for not notifying complete details of the deceased).

2. That the Police Service provide instructions for dealing with Murri Watch Cell Visitors.

3. That the Queensland Police Service, in conjunction with the Board of Murri Watch, conduct a review of operational procedures for the scheme in light of identified deficiencies.

4. The Queensland Police Service consider formulating guidelines regarding the form, nature and extent of prisoner inspections to ensure procedural consistency and early detection of prisoners who are at risk or otherwise require medical attention.

5. i. That the Queensland Police Service take such further measures as are necessary to ensure that all police permanently assigned to watch-house duties are provided with formal instruction in first aid including resuscitation and operation of the oxy viva; and

ii. The Queensland Police Service continue to provide formal pre-service and in-service training in procedures under the new Custody Manual.

6. That Queensland Police Service provide instructions to all watch-house staff to ensure the provision of accurate, precise and complete information in communications with officers of the Queensland Ambulance Transport Board.

7. That Queensland Police Service consider amending Chapter 11 of the Custody Manual to provide practical guidelines and instruction to appropriate members of the Queensland Police Service in the thorough and impartial investigation of deaths in custody in light of identified deficiencies.

8. That the Queensland Police Service, in conjunction with other agencies, implement recommendations 6-40.

9. That there be some restriction on the right of witnesses to claim privilege in respect of testimony which may incriminate or tend to incriminate the witness. (Noting that the Department of Justice and Attorney-General's discussion paper in the course of the Government's review of the Coroner's Act 1958 refers to the right to refuse to answer incriminating questions.)

Additional Royal Commission Recommendations Breached

R7 Specific State/Territory Coroner for inquiries.

R8 Development of specific rules for inquiries and inquests.

R12 Legal requirement for Coroner to consider how the person was treated before death.

R13 Coroner to recommend ways to prevent further deaths.

R18 Annual Reports to include recommendations to prevent further deaths.

R35 Police investigations should: be approached on the basis that the death may be a homicide; inquire into the arrest or apprehension, lawfulness of custody and treatment and supervision of the deceased; and thoroughly examine the scene of death and forensic exhibits.

R36 Investigations of a death in custody should be structured to provide a thorough evidentiary basis for the coroner.

R79 Abolition of offence of public drunkenness.

R80 Adequately funded custodial care to accompany abolition of this offence.

R81 Statutory duty to consider and use alternatives to police detention of intoxicated persons.

R137 Regular checks of persons in police custody.

R226 Inquiries into complaints into police misconduct to be conducted publicly.

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41QLD

Male 24, died on 12 November 1992
Ross River, Townsville, Qld
Drowning

Coronial Inquiry by Coroner Fisher

Finding handed down 22 July 1994

Finding

The cause of death was found to be drowning. The Coroner was not of the opinion that the evidence adduced is sufficient to put any person on trial for any offence arising from this death.

Summing Up

Circumstance of Death

The findings gave the following account. On the evening of 12 November, the deceased and his brother were seen at a vehicle owned by the Manager of a local night club. The manager, with at least five other men, chased the brothers who ran to the creek bank, jumped in and started swimming across towards the southern bank. One person swam after them.

About three-quarters of the way across Ross Creek, the deceased swam around the marina and his brother submerged. Another of the pursuers dived in and assisted the pursuer in the water to take the deceased's brother to the northern bank of the creek. Police arrived on the scene at about this time.

The deceased was sighted a couple of minutes. Other pursuers jumped in and grabbed him. There was a general struggle where, on the evidence, each of the parties from time to time submerged and resurfaced. One of the pursuers attempted to grab the deceased from behind and was bitten on the fingers. Another struck blows to the deceased's head, the second of which resulted in bringing his fist into the deceased's mouth area whereupon he was bitten on the right index finger.

The pursuer released his finger from the deceased's mouth who was underwater at that time. No further contact was made. The three pursuers in the water spread out and waited for the deceased to resurface, but he was not seen alive again.

At about 6.20 am on 13 November 1992, the deceased's body was found by one of the people from a vessel moored in the Creek only a short distance from where he was last seen alive. The forensic pathologist was unable to find any physical marks or injuries, internal or external, which may have caused or contributed to the deceased's death.

Issues

The pursuers, particularly those from the night club, engaged in what the Coroner described as a very willing and zealous search for the deceased both on and around the marina, with very vocal and the abounding use of loud, offensive, obscene, and racist language.

The Coroner commented that the non-action of police officers at the scene has drawn criticism both in the evidence and by way of cross-examination in the matter. Submissions by both counsel assisting and for the next of kin called for the matter to be referred to the Criminal Justice Commission.

Recommendations

1. That the transcript of proceedings be provided to the Commissioner of Police for consideration of such review as may be necessary for practices involving:

a. persons evading or attempting to evade capture by means of swimming; and

b. the control of such situations when the police officers are present, particularly when involving non-police participants.

2. That a copy of the transcript, statements and materials be provided to the Criminal Justice Commission to examine whether there is any official misconduct in relation to the action or non-action of the police officers in this matter.

Royal Commission Recommendations Breached Nil

Social Justice Commissioner

Comment

The post mortem noted irregular pressure marks on the nose not commented upon by the Coroner. High blood alcohol levels were also detected in the post mortem analysis. Neither of these factors were mentioned in the findings. Arguably, both are reasonably likely to have been contributing causes of death.

No comment was offered on the evidence that pursuers struck the deceased on the head while he was underwater and after he had been swimming for some time. This, coupled with the pathology evidence, indicates that physical force was used against the deceased. It raises the question of what would have constituted 'sufficient evidence to put any person on trial for any offence arising out of this death'.

An inspector at the Inquest agreed that the pursuers 'behaved like vigilantes' 9 and yet no action had been taken by police. One of the police officers gave evidence that 'he heard one of the pursuers say "the black bastard's bitten me, I'm going to kill him"'. 10 No explanation was sought or given for the police decision 'not to intervene in the pursuit, as [they] just wanted to observe them.' 11

It is noted that the family of the deceased have called for criminal charges to be laid against those involved in the pursuit and attack on the deceased, and an investigation into the actions of police in allowing it to continue. 12 The latter will be presumably addressed by the CJC investigation into whether, on the Coroner's findings, there was official misconduct by police.

Other Royal Commission Recommendations Breached

R7 Specific State/Territory Coroner for inquiries.

R12 Coroner be required by law to investigate quality of custodial care prior to death.

R35 Police investigations should: be approached on the basis that the death may be a homicide; inquire into the arrest or apprehension, lawfulness of custody and treatment and supervision of the deceased; and thoroughly examine the scene of death and forensic exhibits.

R95 Where motor vehicle offences are a major factor in imprisonment, programs to be consultatively developed to reduce incidence.

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43QLD

Male 27, died on 4 December 1992
Townsville Prison, Qld
Self-inflicted, Hanging

Coronial Inquiry Coroner John Beck at Townsville Coroner's Court

Finding handed down 26 April 1995

Finding

The deceased came by his death from hanging, inflicted on himself after having secured part of a cell mattress cover to a vertical bar above the door of the cell and also around his own neck. The significant contributing factor was that the mind of the deceased was unbalanced by paranoid schizophrenia. This death did not result from any of the offences set out in the Coroner's Act and no person is committed for trial.

Summing Up

Circumstances of Death 13

The deceased was sentenced to nine years imprisonment. The deceased was approved for transfer from Lotus Glen Prison (Cairns) to Rockhampton Prison to be near his only blood relative, his sister. However, he was kept in transit at Townsville Prison from 22 October 1992, for six weeks by the time he died. The deceased was placed in a cell alone on the dilapidated top floor of C wing at Townsville Prison.

In early November, assault charges were laid against the deceased as a result of an altercation with two prisoners. He was placed in an observation cell on 28 November after lighting a fire, barricading himself in his cell and telling prison officers that he was hearing voices and wanted to see a doctor.

A nurse placed him on 'strict observation,' and the visiting Government Medical Officer (GMO) advised her by telephone to sedate the prisoner nightly. The GMO visited on 30 November and refused his request to be taken off strict observation.

Entries in the Log Book on 2 December included: '[the deceased] was displaying very irregular behaviour. Believes everybody is plotting against him. Use caution when dealing with him' and '[the deceased] is very upset. Claims detention unit trio were going to bash him tomorrow at Court'. He was taken to the court in Townsville to face the assault charges on 3 December, but the matter was adjourned because the deceased was not making any sense to his solicitor.

He was found hanged in his cell at approximately 3.30am on 4 December. The officer was not in possession of a radio or the cell-keys for the observation cells and hurried back to another building for the keys. No resuscitation was attempted.

Issues

The Coroner was highly critical of the delay in the transfer of the deceased. He recommended that 'transfers be arranged so that they involve an absolute minimum of en route accommodation'. The Coroner considered that this prolonged stopover was the 'catalyst that proved to be too much'. He had arrived at the Townsville Correctional Centre on 22 October and was still there at the time of his death, 4 December.

The Coroner expressed concern at the lack of information Townsville Prison personnel had regarding the deceased's medical condition.

The Coroner was also highly critical of the length of time taken to receive the psychological autopsy report - one year from the time the request was made. He considered it was unsatisfactory that the task was given a low priority in Queensland Health.

The Coroner also expressed various frustrations with the inquest in the media. 14 He criticised the Corrective Services Commission for trying to exclude details of an internal report from the inquest 15 and 'taking points on matters of relative insignificance'. He noted a 'veiled threat of judicial review or other appeal' from the Crown Solicitor if the ruling was 'not to his liking'.

Recommendations

1. The transfer of prisoners be so arranged that they involve an absolute minimum of en route accommodation.

2. No prisoner to leave one correctional centre en route to an intermediate correctional centre unless it is also arranged that he depart that intermediate centre within at least one week of his arrival at the intermediate centre.

3. Adequate medical information to be transferred with prisoner to relevant health professional.

4. Prisoners not be transferred unless approved by the medical officer.

Royal Commission Recommendations Breached

R27 Lawyers appointed to assist Coroner may be a Crown Law Officer or counsel, but to be independent of custodial authority.

R28 Lawyers appointed to assist the Coroner to have certain duties.

R37 Post mortem be conducted by a specialist forensic pathologist.

R153 Ongoing review of prison health services, with confidentiality issues between prison staff and prisoners to be addressed

R157 Medical files were not transferred when deceased was transferred from Lotus Glen.

Social Justice Commissioner

Comments

Despite the gravity of the circumstances, the Coroner stated enigmatically: 'I do not consider that I should be expected to be making recommendations on whatever aspect of the operations of the Corrective Services Commission the evidence suggests to me to review it'. The Coroner's findings are therefore sketchy and amount to two and half pages. This is not consistent with recommendations 12 and 13. The Queensland Deaths in Custody Overview Committee stated their intention to subpoena the Coroner to justify his actions on the grounds that the inquest was inadequate and the findings unjustified.

The internal report into the death revealed a myriad of problems. 16 The Townsville Prison General Manager did not know of the prisoner, his transfer, or his transit status. The Custodial Corrections Manual requires that transfers be documented and forwarded to the Manager, which did not happen. There was no knowledge of a psychiatric review reporting that the deceased could act suicidally. The internal report noted that there was no way for a prisoner in or near an observation cell to contact staff in an emergency, which was inadequate for a prisoner at risk. The prisoner's behaviour and needs screens on the Commission Correctional Information System were not completed. The Corrective Services Inspector revealed that the cell had been cleaned before the internal investigators were given access. He also recorded that the deceased was placed in a detention unit after an argument with a prison officer without a hearing, a contravention of the Corrective Services Act.

The prison counsellor who spoke to the deceased did not act on his complaints of delays in his transfer, nor responsd to his request for paints to continue his traditional painting. 17

The report indicated that discussions and interviews with senior management of the prison, staff, inmates, official visitors, chaplains and others revealed virtually a complete lack of programs available to the inmates at the Harold Gregg Units. There had been no education officer for some time, the psychologist and one of the counsellors resigned prior to the incident, the library was open for 30 minutes per Unit per week, and there was limited access to the gym and the oval. Sentence/Case management in the centre was simplistic, due not to the Sentence Management Co-ordinator, but rather to the lack of participation by officers, program officers, counsellors and psychologists. Psychological assessment was not undertaken and even the simple needs identified in Sentence/Case Management were not followed-up by the program officers. There was no Aboriginal Welfare Officer at the prison.

Human Rights Commissioner Burdekin attacked the Queensland Government for using wings B and C of Townsville Prison, where the deceased died. Four Aboriginal people had died in the prison during the Royal Commission period, and three more have died there since. He had earlier condemned the wings as unfit for human habitation, as there was no water supply or sewerage system. He stated that the 'conditions are filthy, mud, slush and excrement cover floors to a depth of some centimetres' and that they breached international human rights treaties. The bars provided a hanging point and the mattress cover provided a ligature. The Corrective Services spokesman stated that it was necessary to re-use these wings because of a fire in newly built cells. The Human Rights Commissioner responded that the 100 year old cells should not be used under any circumstances. A death in the same cell had been examined by the Royal Commission 18 - the Government had been put on notice.

The deceased's sister has commenced a negligence action against the Queensland Government and the QCSC in relation to the death.

Additional Royal Commission Recommendations Breached

R7 Specific State/Territory Coroner for inquiries.

R8 Development of specific rules for inquiries and inquests by a state coroner

R12 Legal requirement for Coroner to consider how the person was treated before death.

R13 Coroner to recommend ways to prevent further deaths.

R123 Instructions on care of persons in custody to be known, understood, enforceable and publicly available.

R150 Health care should be of equivalent standard as general community.

R151 Referral of Aboriginal prisoners/detainees for psychiatric care.

R152a Review of health services provided to Aboriginal detainees with AMS and other bodies to consider standard of health services available.

R152d Facilities for behaviourally disturbed.

R152g(iv) Protocols for care and management of Aboriginal prisoners who are at risk of self-harm.

R152g(vi) Protocols for care and management of Aboriginal prisoners who suffer from a mental illness.

R155 Training of prison officers to include Aboriginal health information, risk assessment and appropriate emergency action to be taken.

R158 First priority on finding a person apparently dead to be resuscitation and medical assistance.
R159 Availability of safe, effective resuscitation equipment and trained staff in all prisons and watch-houses.

R165 Elimination of potential hanging points and materials.

R168 Aboriginal prisoners to be as close to family as possible; right of appeal against transfer further away.

R173 Support for humane and shared custodial accommodation.

R174 That Aboriginal Welfare Officers be employed in prisons.

R179 That prisoner requests were to be settled by staff, and procedures simplified.

R181 Aboriginal prisoners not to be isolated with minimum standards for segregation including fresh air, lighting, daily exercise, adequate clothing and heating, adequate food water and sanitation facilities and some access to visitors.

R184 Corrective services ensure opportunities for meaningful work, self-development, Aboriginal history and culture.

R329 Legislation to embody Standard Guidelines and prisoners rights as in Victoria.

R331 National Standards Body formulate adoption of guidelines directed towards needs of Aboriginal prisoners.

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45QLD

Male 21 died on 7 April 1993
Arthur Gorrie Remand and Prison, Qld
Self-inflicted, hanging

Coronial Inquiry Coroner Casey at Brisbane Coroner's Court

Finding handed down 7 March 1994.

Finding

The cause of death was hanging. The deceased had of his own volition, utilised socks to suspend himself from the bars above his cell.

The Coroner was unable to find any evidence of a criminal nature that may be imputed to any person and no person is to be committed for trial with respect to this incident.

Summing up

Circumstances of Death

The deceased was arrested on 5 April on charges including obscene language, resist arrest, break and enter, and unlawful use of a motor vehicle.

He was transferred the same day from the Brisbane Watch-house to the Arthur Gorrie Remand Centre. The Government Medical Officer formed the opinion that the deceased was a suicide risk. He was administered medication and remained in the holding cell of the surgery until he was subsequently examined by the visiting medical officer on 6 April 1993.

On 7 April 1993 the same medical officer examined the deceased and formed the view that the deceased could take his place in the general correction community. He was allocated a cell in the general prison, and supplied with an issue of property for his personal use.

The lock down occurred at 9.45pm. At 10.15pm a head count was conducted of the unit and the deceased was discovered hanging in his cell. Despite resuscitation attempts, the deceased was pronounced dead shortly after his arrival at Princess Alexandra Hospital at 11.07pm.

Issues

The Coroner commented that to examine issues in the findings he must be satisfied of the real need to do so in the circumstances under examination.

The Coroner found that steps had been taken since the death at the prison to implement protocols for the care and safety of inmates, and mentioned a general manager's rule to identify and treat inmates considered to be at risk of self-harm. He referred to other measures which potentially enhance the standard of correctional management. The Coroner was impressed with the 'concepts of a high risk assessment team; the provision of a special night observation unit, and the ancillary buddy system of support to at risk inmates; and the introduction of relaxation techniques and stress management courses for inmates'. He noted that the principles would potentially benefit all correctional centres in Queensland.

Recommendations

The Coroner 'offered the suggestions that:

1. The role of an Aboriginal, whether in the capacity of a counsellor or as an advisory member of the high risk assessment team, be utilised specifically where the inmate under assessment is of Aboriginal descent;

2. An Aboriginal nurse, if available, be present during medical examinations and assessments of Aboriginal inmates and the services of a male nurse be utilised wherever practicable; and

3. That where practicable members of an Aboriginal family be consulted when ascertaining the medical, psychiatric or psychological profile of an Aboriginal inmate.'

Royal Commission Recommendations Breached

R91 Consideration with ALS and police of amending bail legislation to enable review of police denial of bail, revision of inappropriate restrictions on granting bail to Aboriginal people.

R152c AHS involvement in review of prison medical services.

R152g(iv) Protocols for care and management of Aboriginal prisoners at risk of self-harm. R154c Efforts to employ Aboriginal people in prison health services.

R174 Employment and location of Aboriginal Welfare Officer by Corrective Services

Social Justice Commissioner

Comment

The deceased had been convicted for around sixty previous offences, most of them minor, the first when he was 12 years old.

The Coroner commented that 'In making these findings I am not permitted under the provisions of subsection 5 to express any opinion on any matter outside the scope of the inquest except in the form of a rider designed to prevent similar circumstances'. This peripheral role is at odds with Royal Commission recommendations 6 to 40 relating to the coronial process. The critical role that coroners play in preventing further deaths, and the need for thorough investigations into the underlying causes of death, were emphasised by the Royal Commission.

Public suspicions were raised in press reports that, during the arrest, police bashed the deceased while he was holding his baby. 19 The Coroner should have dispelled these suspicions and investigated the arrest, just two days prior to the death, but he made no reference to the arrest at all. According to newspaper reports a writ claiming damages on behalf of children of deceased was issued in Queensland Supreme Court, 7 March 1994. 20

The death involved a young unsentenced remand prisoner. He had been moved from the Brisbane watch-house as a suicide risk on the day of his arrest, and was given unspecified medication on reception at Arthur Gorrie because he was a suicide risk.

He was reclassified as not at risk two days later, on the day of the suicide. It seems he was placed in a cell by himself. The Royal Commission recommended elimination of items with the potential for self-harm. The deceased hung himself with prison socks. The circumstances indicate a need for extra procedures. Because he found that some new procedures had been put in place, the Coroner did not investigate the circumstances of the arrest, medical assessments or death.

The Royal Commission generally supported greater access for family members and a lessening of obstacles to visits. A request by the deceased's immediate family to visit him in the Correctional Centre was denied. The rules allowed week-end visits only.

The case demonstrates the crucial need for a transition period for remand prisoners.

Additional Royal Commission Recommendations Breached

R7 State Coroner, or a coroner specially designated to deal with deaths in custody, to be responsible for inquests into deaths in custody.

R8 Development of specific rules for inquiries and inquests.

R12 Coroner required by law to investigate the quality of care, treatment and supervision of the deceased prior to death.

R13 Coroner to recommend ways to prevent further deaths.

R35 Police investigations should inquire into the arrest or apprehension, lawfulness of custody and treatment and supervision of the deceased

R87a Police to apply arrest as a final sanction.

R95 Where motor vehicle offences are a major factor in imprisonment, programs to be consultatively developed to reduce incidence.

R165 Elimination/reduction of items with potential for self-harm.

R175 Consideration of a short transition period before entering prison routine.

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53QLD

Male 18, died on 7 November 1993
Police custody, Brisbane Qld
Heart Disease

Criminal Justice Commission Investigation

Conducted by Commissioner Lew Wyvill QC

Report handed down 23 March 1994

Finding

That the deceased died from:

1. a. Ischaemic heart disease;

b. Coronary artery stenosis;

c. Coronary artery atheroma, and

2. Drug intoxication.

Summing-Up

Circumstances of Death

On 7 November 1993 the deceased and seven companions, most of them members of the Waka Waka Dance Troupe, went to Southbank Parklands in Brisbane. There was some mention of an altercation between the deceased and an unknown person. They were later moved on by a security guard, which upset them. They went to Musgrave Park, South Brisbane, where they did some drinking. They were observed by Police Officers A & B from a police van. The officers alleged that several youths swore threateningly at police and one of the youths exposed himself.

The group left the park along Edmonstone Street towards the hostel where they were staying. The group swore at the police in the van and told them to leave them alone. Police claim that the group made threatening gestures at themselves and at motorists. Police radioed for assistance:

'[Police Officer B] here. We're in Edmondstone Street at the moment. There's 7 or 8 Aboriginal persons fairly, sort of giving us a few problems� [at that point an unknown voice can be heard calling out 'piss off'] and calling us names. They're all F.O.P. We'd like some persons to come down and give us a hand if you want to come down.

When the other car advised that they were busy and could not come down Police Officer A said:

Yeah. I'll just get another car. I just thought you might be around 'cause you love that type of stuff. You would have loved it. No worries. Thank you.

The group arrived at SEQEB park. The following call was made:

They're outside SEQEB in Boundary Street. They're going toward to the hostel so I would appreciate it if any other unit can get down there pretty quick.

Two more police vehicles arrived. The deceased went to ground fairly heavily when he reportedly collided with, or was shoulder blocked by, Police Officer C whose presence he was not aware of.

One member of the group picked up a wooden stake when he saw the deceased being apprehended. He dropped it when told to do so by police. Two officers remained with the deceased, who was handcuffed with his hands behind his back. Allegations were made that Police Officer A kicked or punched the deceased, and that the handcuffs were too tight. The deceased vomited and urinated while lying on the ground. The evidence indicated the deceased was at the least semi-rousable, and that another Aboriginal youth moved his head for him when he began to splutter. The Commissioner attributed this to intoxication. He was then placed on the ground in the back of a caged van.

Another police van went to the hostel. Things were thrown at police by residents of the hostel. The police entered and arrested another member of the group, who was put in the police van with the deceased. The other youth alleged that he yelled out several times that the handcuffs were too tight, and indicated that the deceased would not wake up. The Commissioner found that the other youth thought the deceased was not sick, but merely sleeping in the van.

The police van patrolled the area looking for other members of the group. The deceased was in the back of the van for approximately half an hour. Police Officer A gave evidence that she made a brief visual check of the deceased when the second prisoner was placed in the van, and that his eyes were open and blinking. The deceased had no pulse on arrival at the watch-house. Police attempted resuscitation, and an ambulance was called. Resuscitation procedures were continued in the ambulance and at Royal Brisbane Hospital. Although the heart did respond briefly, the deceased did not recover.

Issues

The Criminal Justice Commission (CJC) rather than a coroner investigated the death because of the protest which followed, and because of the seriousness of the allegations raised. The Terms of Reference were:

a. whether there is any evidence of criminal offence, official misconduct in any other form, misconduct including neglect or violation of duty by any member of the Queensland Police Service in relation to the death;

b. whether the relationship between members of the Police Service and members of the Aboriginal community had a bearing on the circumstances of the apprehension; and

c. whether any changes are necessary to Police Service policies, procedures or operations instructions in relation to the apprehension.

The Commissioner found there were inconsistencies in police allegations of wilful exposure in Musgrave Park, and that it was unlikely anything of that nature had occurred. The Commissioner also found the allegation that the deceased had waved a stake at police was false.

The Commissioner relied heavily on medical evidence from the autopsies. The deceased had a history of syncopal events, fainting spells and temporary heart failure resulting from Stokes-Adams disease. Because there was some response from CPR, at Brisbane Hospital, the medical expert gave evidence that the heart failure had occurred five or ten minutes before arrival at the watch-house.

There were three injuries to the head of the deceased. The independent forensic specialist stated that they were consistent with a kick or a punch, but were not accompanied by bruising as would be expected if resulting from violence. If inflicted during death the lack of bruising was not unusual. Because death was found to have occurred later, the cuts were found not to be the result of mistreatment during the arrest.

Evidence of the Aboriginal youths and independent witnesses who claimed they witnessed mistreatment was discounted.

Police Officer A claimed she only called for assistance when the deceased threatened them with stakes in SEQEB park. This conflicted with the transcript of the call by Police Officer B. Stakes were not mentioned in calls for assistance or in interviews soon after the incident.

The Commissioner found:

1. There is sufficient evidence to show that the deceased and companions were acting in a disorderly manner along Edmondstone St and in the SEQEB park area and, that being so, the deceased's arrest was lawful.

2. The evidence does not support a finding, even on the balance of probabilities, that the force used by Police Officer C in effecting the deceased's arrest was excessive.

3. As to whether the deceased's arrest was appropriate, in hindsight it may have been more prudent for Police Officers A and B to first contact a superior officer for advice and direction as to the course of action for them to adopt. However, it is accepted that officers have to make decisions on patrol and do not have the benefit of hindsight. In fact, if Police Officers A and B had contacted the officer in charge at West End he would have advised them to have contact with the group despite the obvious potential for conflict.

4. The evidence is not sufficient to support allegations that the deceased was mistreated following his arrest.

5. It is more probable than not that the deceased was not unconscious while on the ground and whilst being placed in the police van and, further, it is more probable than not that any observable change in the deceased's condition whilst on the ground and when placed in the police van was a result of intoxication and not of any condition requiring medical attention.

6. The evidence establishes that it is more probable than not that -

a. the deceased's condition did change whilst in the police van but not until after it had left Boundary Street and was in transit to the watch-house;

b. this change in the deceased's condition was as a result of the Stokes-Adams attack; and

c. a change in the deceased's condition did not come to the notice of the police and they were unaware of it until he was removed from the police van in the watch-house car park.

7. There is not sufficient evidence to support a conclusion that there was any failure to exercise care for the deceased while he was in police custody.

8. There is not sufficient evidence to support a prima facie case against any member of the Police Service on a charge of manslaughter or any other criminal offence nor is there sufficient evidence to support proceedings against any member of the Police Service for official misconduct or misconduct including neglect or violation of duty.

The Commissioner noted that while the police response was correct from the point of view of a response to incident model, it was not satisfactory as a response to the deeper problems such incidents represent.

Recommendations

The Commissioner recommended the adoption of a proposal for beat policing in the West End police district. Beat officers would work alone, be responsible for police/community liaison as well as mainstream services, and concentrate on total community responses and improved relationships rather than 'treating symptoms of deeper problems via - often inappropriate - use of the criminal law'.

The Commissioner also made the following recommendations:

1. Police Officer A should undergo further training in relation to the obligations that the custody manual imposes on police officers to make a careful assessment of the condition of prisoners in their custody.

2. Appropriate training should be given to all officers to ensure that an assessment of a prisoner's condition is made, not only at the time of arrest but also at appropriate intervals whilst the prisoner is in the custody of police officers prior to his or her arrival at the watch-house.

3. Urgent consideration should be given to the establishment of a means of communication between the occupants of special purpose vehicles of the type involved in this case and those persons imprisoned in the secure area of those vehicles.

4. The handcuffing procedures laid down by the Police Service should be reviewed to ensure that officers have a discretion not only as to whether an offender is initially handcuffed but also as to whether the handcuffs remain on that person. The training material tendered before the hearings indicates that officers are instructed that 'wherever and whenever possible a prisoner should be handcuffed with his hands behind his back and handcuffs are not to be removed from a prisoner other than at a place of safety (watch-house, police station, prison etc)'. It was as a result of this material that the Commissioner considered that the officers involved in the arrest and detention of the deceased cannot be criticised in leaving him handcuffed with his hands behind his back for a period in the order of thirty minutes. However, these officers recognised that persons with their hands handcuffed behind their back are incapable of using their hands to control their position.

That being so, it is difficult to place them in a position other than on the floor of the police van. Once a person is placed in the van they are in a secure area. If the person is subdued, there would seem to be no reason why the handcuffs should not be removed.

5. The Police Service should ensure that all serving officers have access to and study the contents of the Custody Manual. While a Commissioners Circular in relation to the Custody Manual was tendered in evidence, the evidence of Police Officers A and B indicates that they did not have sufficient, if any, knowledge of its contents. The evidence of the officer-in-charge of the West End Police Station also indicates there was an inadequate system in place to ensure all officers complied with the circulars and familiarised themselves with the contents of the Custody Manual.

6. The debriefing procedure laid down by the Police Service should be reviewed to have regard to the need for officers to give their own recollection of events as soon as possible after an incident, such as the incident involving the deceased. The debriefing session in this case, while conducted in accordance with the guidelines, occurred after an official investigation had commenced but before the officers had been interviewed by the Commissioners. The session involved all relevant police officers, as a group, discussing not only their feelings but also the events in question.

The guidelines should be changed to ensure that in future no debriefing session occurs until after each officer has provided a record of his/her recollection of relevant events. This will prevent any allegation of their account of events having been affected or altered by the accounts given by other officers involved in the incident in the course of the debriefing session.

Royal Commission Recommendations Breached

R122 Police and custodial authorities to recognise their legal duty of care to persons in their custody

R123 Instructions on care of persons in custody to be known, understood, enforceable and publicly available.

R127f(i) Development of rules for care and management of Aboriginal prisoners at risk because they are intoxicated.

R133 Training of police officers to recognise those in distress or a risk.

R137 Police training and instructions to require checks of detainees. More regular checks for detainees at risk.

R141 No-one to be detained without care and supervision.

R163 Regular training of police and prison officers in restraint techniques.

R214 Support for community policing with involvement of Aboriginal communities and organisations in developing procedures in areas where Aboriginal people live or gather.

Social Justice Commissioner

Comment

The investigation was highly sensitive. Scuffles broke out the day after the death between police and Aboriginal people protesting about the incident. The boys who made allegations that the deceased was kicked by Police Officer A received criticism from the Commissioner.

The Commissioner, the former Royal Commissioner for Queensland, made no reference to the Royal Commission in his report. The investigation focussed on criminal liability rather than safety procedures. The Queensland Government adopted the recommendations of the Royal Commission, so the recommendations were relevant to an investigation of the appropriateness of the police operation.

It is inappropriate to speculate on the facts. Many people still doubt that an extremely fit 19 year old, even allowing for a blood alcohol level of .197 per 100mg, would shift from full consciousness and boisterous conduct to impaired consciousness as a result of an arrest which did not injure him.

There seems to have been little basis for the arrest operation involving six police. The incident was sparked by police surveillance in an area traditionally used by Aboriginal people. 21 The swearing and abuse in a public street was held to constitute offensive behaviour under section 7 (e) of the Vagrants, Gaming and Other Offences Act 1931 (Qld). The Aboriginal Legal Service argued that the offensive behaviour was merely a response to inappropriate scrutiny. The Commissioner dismissed this submission and relied on the fact that the conduct occurred in a public street near houses. This finding has been controversial.

The evidence of the officer-in-charge was that he would have approved contact with the youths had he been contacted. It is doubtful whether this indicates that the arrest was appropriate. The Commissioner found it did. However, police were found to have exaggerated the nature of youths' offensive behaviour leading to the arrest, so it is unclear whether the officer-in-charge would have approved contact with the group for the lesser conduct. The appropriateness of the decision of the officer-in-charge was not considered. The Royal Commission recommendations about police not initiating contact or arresting on trivial charges, which the Queensland Police Department claim to have adopted, were not considered (R86, R87, R239, R240 and R245).

That the arrest was found to be legal serves to highlight the breadth of police arrest power. The case raises questions about the policing of 'public spaces'. It is unjust and unnecessary to criminalise Aboriginal people who do not relate culturally to the strict liberal concept of differentiated private and public domains.

Term of reference (b) was answered in the negative by the Commissioner because the police would have treated any persons drinking in the park in the same way. This finding is artificial given the history of the park being used as a drinking area by Aboriginal people. Disappointingly, this finding led the Commissioner to state that he was not required to address term of reference (c).

The Commissioner underplayed the racial context of the policing. Boundary Road, at SEQEB Park, was the street which indicated as recently as the 1920s the line which Aborigines could not cross without a pass, an apartheid sealing off of the city. The park is regularly used by Aboriginal people. In this case, the police were somehow sufficiently familiar with the youths to know they were heading back to a particular hostel. The history of criminal justice in Queensland reveals why Aboriginal people are sensitive to the kind of scrutiny that was exerted in this case.

The Commissioner consistently exonerated the police from allegations of serious misconduct. Custodial care was found not to warrant criminal or disciplinary proceedings. Medical care should have been sought if doubts arose as to the medical condition of the deceased. Many witnesses indicated the deceased had to be helped to the van and was semi-rousable. However, the Commissioner found that this was solely due to intoxication. It does not seem that any proper examination of the prisoner took place. Of course, doubts could not arise in the absence of a medical examination. The requirements of recommendation 161 were not satisfied.

The matrix of events, including the initial radio message, the surveillance and the incarceration of a semi-rousable detainee in the back of a police van leads to the conclusion that the recommendation for the elimination of rough treatment by police was breached (R60). The events do not indicate humane contact (R134). The fact that the guidelines on handcuffing mandated aspects of the treatment merely makes that aspect of the breaches more serious.

Additional Royal Commission Recommendations Breached

R60 Elimination of, and disciplining for, rough police treatment, verbal abuse of Aboriginal persons and use of racist or offensive language.

R84 Public drinking issues to be negotiated locally with police, ALS and Aboriginal organisations.

R85 Monitoring to ensure arrests for minor charges do not replace arrests for drunkenness.

R86 Offensive language during police initiated action not to be basis for arrest and charge.

R87 Police to apply arrest as a final sanction.

R134 Police instructions to require humane and courteous contact with detainees.

R135 People unconscious or not easily roused to be taken to a medical service, not a watch-house.

R161 Seek medical attention if doubts arise as to the condition of the prisoner.

R215 Police to introduce procedures for local negotiation on police methods and perceived discrimination problems.

R231 Governments to improve their Aboriginal relations actions in the light of experience.

R239 Review of laws and of police standing orders to favour non-custodial alternatives to arrest of Aboriginal youth.

R240 Police to use cautions rather than arrest, summons or attendance notice, preferably with guardian present.

R245 Amendment of legislation, regulations and police standing orders to put recommendations 234-244 into action.

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55QLD

Male 22, died on 9 January 1994
Lotus Glen Prison, Qld
Natural Causes, Heart attack

Coronial Inquiry Coroner Moreton SM

Finding handed down 30 March 1995

Findings

The deceased died from: acute myocardial infarction; coronary thrombosis; and coronary atherosclerosis.

Summing Up

Circumstances of Death

The deceased was serving a six month sentence for a break and enter offence. On the morning of his death, the deceased played a game of football after which he went to the prison hospital. At approximately 11:20am he complained to a nurse of a sore shoulder and pain in the sternum area, up to his midline towards his throat. A blood pressure and pulse check was taken. His symptoms were considered normal for someone of the deceased's age who had just participated in a game of football. He was given treatment and he left the hospital.

At approximately 12:45pm the nurse had a prison officer check the deceased. The deceased indicated he did not want to see the nurse. At approximately 5pm the deceased was found by a fellow prisoner who alerted the guards. Medical attention was given by the duty nurse and others. However, life was pronounced extinct on the arrival of the doctor.

Issues

The Coroner only related the above facts and stated that he did 'not intend to make any recommendations arising out of this death in custody'.

Recommendations Nil

Royal Commission Recommendations Breached Nil

Social Justice Commissioner

Comments

Prior to the inquest, letters addressed to the Mareeba Coroner and the head of the Mareeba police district by the Indigenous legal service acting for the deceased, asked for details of the investigation. 22 The Coroner's reply answers few of the questions asked. The Inspector of Police stated in his reply that he believed it would be improper to canvass the issues raised or to provide any particulars to the legal representatives for the family prior to the inquest. The inspector viewed recommendation 24 as 'improper,' despite claims that it had been implemented. 23

The Coroner's failure to investigate any of the broader circumstances of the death was unfortunate. One obvious issue is the apparent lack of awareness by medical staff at the prison of the susceptibility to heart disease of Aboriginal people, even young Aboriginal people. Aboriginal people who present with symptoms of chest pain should be given more than a pulse and blood pressure check.

The benefits of a centralised coronial system, and a designated coroner to oversee all deaths in custody and develop expertise in the area, is illustrated by this death. Coroner's annual reports which include summary recommendations and findings of inquests would ensure that systemic problems can be recognised and addressed.

Additional Royal Commission Recommendations breached

R7 Specific State/Territory Coroner for inquiries.

R12 Legal requirement for Coroner to consider how the person was treated before death.

R13 Coroner to recommend ways to prevent further deaths.

R24 Coroner to provide information sought by the counsel for the family or the Aboriginal Legal Service.

R154a Training of Prison Medical Services staff to ensure they understand Aboriginal health issues.

R155 Training of prison officers to include Aboriginal health, information, risk assessment and appropriate emergency action.

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58QLD

Male 32, died on 12 March 1994
Rockhampton Prison, Queensland
Heart Attack

Coronial Inquiry Coroner S Bradley at Rockhampton Coroners Court

Finding handed down 3 March 1995

Findings

The cause of death was coronary atherosclerosis.

Summing Up

Circumstances of Death

The deceased was last seen alive by a fellow prisoner at approximately 7.30am. The Coroner reported evidence from prison officers that his cell had been unlocked at about 6.10am and everything appeared normal. After a conversation, the deceased indicated he was going to his cell for a sleep. Some time later, other inmates came into the cell and saw the deceased lying on his bed face down. It was thought the deceased was asleep or fooling around.

Some time after 11.00am, a fellow inmate went to wake the deceased for lunch. It was noticed then that the deceased had not moved and attempts to rouse him were unsuccessful. No pulse was detected and the prisoner officer advised the medical staff, the High Medium Senior Officer and the Operations Unit.

The nurse who was notified could find no vital signs and a doctor declared life extinct at approximately 1:30pm. A post mortem found severe coronary disease involving two of the three main vessels to the heart.

Issues

The deceased had been serving his third custodial sentence at the time of his death, having served ten months of a seven year sentence for grievous bodily harm. According to the Coroner, the deceased's offending behaviour appears to have resulted mainly from alcohol abuse. Some minor health problems were present and being treated but there was no apparent reason to suspect the heart condition. This was confirmed by fellow inmates and the deceased's family.

Prison records describe him as a 'violent offender'. However, prison staff provided evidence that the deceased was a quiet and well liked prisoner and expressed genuine grief at his death. A statement to the inquest from the deceased's brother outlining the family history was found by the Coroner to make sad reading and to bear testimony to the low life expectancy of Aboriginal people.

The Coroner concluded that the deceased was given appropriate and adequate medical attention whilst in custody and his death could not have been foreseen. He had been dead for some time prior to being discovered and it was quite apparent that any attempts to resuscitate him would have been futile. The only indication of underlying heart disease was a history of indigestion and statements from fellow inmates and the deceased's family 'indicated that none had any knowledge of any heart problems'.

A thorough investigation of the death, which included securing the deceased's cell and statements taken from forty-nine witnesses and medical and prison personnel, concluded that there were no suspicious circumstances surrounding the death of the deceased.

Recommendations Nil

Royal Commission Recommendations Breached Nil

Social Justice Commissioner

Comments

The post death investigations were thorough and the investigating team is to be commended for the way in which they were conducted.

Additional Royal Commission Recommendations Breached

R7 Specific State/Territory Coroner for inquiries.

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59QLD

Male 19, died 2 April 1994
Arthur Gorrie Remand Centre, Qld
Self-inflicted, Hanging

Coronial Inquiry Coroner Gary Casey SM

Commenced 14-16 February 1996, no finding to date.

Social Justice Commissioner

Circumstances of Death 24

The deceased was incarcerated on remand for a number of property offences at the time of his death. He was a diagnosed schizophrenic and had been institutionalised. A magistrate transferred the deceased directly to the John Oxley Memorial Hospital when it was apparent he was hallucinating. He was diagnosed and treated for drug induced psychosis from July 1993 to November 1993. The Hospital was apparently unaware that he had been recently diagnosed as schitzophrenic.

The deceased was found hanging in his cell by a sheet tied to the bars of his cell door at around 1:00am by officers carrying out routine cell inspections.

Issues

Medical records were not passed on when the deceased was transferred back to the Arthur Gorrie prison. The admitting nurse gave evidence to the Inquest that the deceased's medical file was not available. It showed that he had made suicide attempts and had been subject to a suicide watch during a period of incarceration at the correctional centre six months previously. The nurse did not attempt to read the file when it became available. Counsel for the family gave evidence that if the deceased had been given his medication for schizophrenia, he would have been able to control his suicidal tendencies, and that if his medical file had been availed of the deceased would have been declared a suicide risk and additional precautions put in place.

The Director of the only hospital where prisoners are sent for treatment, John Oxley Memorial Hospital, has given evidence to the Coroner that he has never been approached by Queensland Corrective Services Commission nor the Commissioner for Health to assist in developing protocols for transfer of information. This indicates that 'at risk' information never accompanies inmates transferred back to the prisons.

It is particularly significant in the context of this study that there were 'constant objections by Counsel for Queensland Corrective Services Commission' who argued that questioning on lack of implementation of Royal Commission Recommendations was not permissible under the Queensland Coroner's Act.

Additional Royal Commission Recommendations Breached

R91 Consideration with ALS and police of amending bail legislation to enable review of police denial of bail, revision of inappropriate restrictions on granting bail to Aboriginal people.

R152e Information exchange between prison and other medical services

R152f Guidelines for exchange of information between medical and prison services

R152g(iv) Protocols for care and management of Aboriginal prisoners who have a history of self-harm.

R152g(vi) Protocols for care and management of Aboriginal prisoners who suffer from mental illness.

R152g(viii)Protocols for care and management of Aboriginal prisoners on medication.

R157 Securing of comprehensive medical history from outside, to accompany prisoner on transfers.

R165 Elimination/reduction of items with potential for self-harm.

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64QLD

Male 35, died on 4 July 1994
Townsville Prison, Qld
Self-inflicted, Hanging

Coronial Inquiry Coroner G Brennan at Townsville Coroner's Court

Finding handed down 29 August 1995.

Findings

The deceased died from hanging. The Coroner stated that there was no evidence any person had contact with the deceased and no evidence any other person was directly involved.

Summing Up

Circumstances of Death

The deceased had been on remand for three months for sex offences. He was last seen alive about 8:30pm on 3 July 1994 by the prison officer who secured him in his cell. The Police Report indicated that the deceased did not appear depressed or indifferent. He was found by the same prison officer at about 6:58am hanging from a ventilation grill by a piece of bed sheet material which was tied around his neck. The deceased was then examined by the prison nurse who stated to police that he appeared to have been dead for about four hours or more. The Police Report also stated that suicide notes addressed to prison counsellors were found in the cell.

Issues

The Coronial finding amounted to a few sentences. The Police Report was one paragraph.

Recommendation Nil

Royal Commission Recommendations Nil

Social Justice Commissioner

Comments

Newspaper reports indicate that at the time of his death, the deceased was placed in segregated accommodation at his own request for safety reasons. 25 The Police and Corrective Services Minister stated that the deceased had been psychologically assessed by psychologists and counsellors within the first two hours of being remanded. 26

They denied that prison authorities had been informed by the Gurrindal Cell Visitors Program that the deceased had made suicide threats while at the Townsville Watch-house before being taken to the Remand Centre. The Minister also stated that there were no reports of intention to commit suicide from the ATSIC Regional Councilors who regularly visited the deceased in prison.

An Aboriginal representative assigned to the post-death investigation made a formal complaint about the process of the investigation, and of tokenism regarding her involvement. For example, the police investigator would begin interviews at 6.00am after arranging to meet the Aboriginal investigator at 9.00am. Prison personnel denied knowledge of the deceased's suicide risk. However, the deceased's medical file was apparently seen to be ticked at the 'high risk' box. Efforts to confirm this were unsuccessful. These complaints and concerns were largely dismissed by the Coroner and the Corrective Services Commission who considered that 'miscommunication' was responsible for the Aboriginal investigator's exclusion from much of the investigation.

The Aboriginal investigator also expressed concern at the segregation cells at the Townsville Correctional Centre, describing them as filthy, dingy and with inadequate sanitation facilities.

This is the second death at Townsville Prison where people involved have claimed that prison authorities have attempted to withhold information (see 43QLD). Further, both coronial investigations have been extremely limited. A proper investigation into the conditions and procedures at Townsville Prison is necessary, particularly given earlier comments by the Human Rights Commissioner (see 43QLD) and the comments by the Aboriginal investigator in this case. The 1996 death of 23 year old man (90QLD), also self-inflicted, should result in an inquest that examines even more carefully the conditions at the prison.

Additional Royal Commission Recommendations Breached

R7 Specific State/Territory Coroner for inquiries.

R8 Development of specific rules for inquiries and inquests.

R12 Legal requirement for Coroner to consider how the person was treated before death.

R13 Coroner to recommend ways to prevent further deaths.

R35 Police investigations should: be approached on the basis that the death may be a homicide; inquire into the arrest or apprehension, lawfulness of custody and treatment and supervision of the deceased; and thoroughly examine the scene of death and forensic exhibits.

R36 Investigations of a death in custody should be structured to provide a thorough evidentiary basis for the coroner.

R145 Establishment of Cell Visitors Program

R152g(iv) Protocols for care and management of Aboriginal prisoners at risk of self-harm.

R155 Training of prison officers to include Aboriginal health, information, risk assessment and appropriate emergency action to be taken.

R165 Elimination/reduction of items with potential for self-harm.

R173 Support for humane and shared custodial accommodation.

R181 Segregation and isolation of Aboriginal prisoners to be avoided. Minimum standards for segregation including fresh air, lighting, daily exercise, adequate clothing and heating, adequate food, water and sanitation facilities and some access to visitors.

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69QLD

Male 20, died on 1 February 1995
Sir David Longlands Prison, Qld
Hanging

Coronial Inquiry Pending

Social Justice Commissioner

Circumstances of death 27

The deceased was found hanging by a skipping rope attached to louvre bars above his cell door shortly after 1:00pm. It was reported that he was last seen alive at 10.30am.

Issues

The deceased was 20 years old, and incarcerated for two years on a range of charges, including, wilful damage, assault, offences under the Bail Act, drink and drive charges and fare evasion. He had been in custody since July the previous year. No other information is available at this stage.

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74QLD
Male 27, died on 20 April 1995
Borallon Prison, Qld
Self-inflicted, Hanging

Coronial Inquiry Coroner Bloxsom, Brisbane

Finding handed down 24 November 1995

Finding

The cause of death was hanging.

Summing up

Circumstances of Death

The Coroner noted that the deceased had been in custody on previous occasions dating back to 1990. On this occasion he was serving sentences for non-payment of fines, dangerous driving and driving whilst unlicensed. His ineligibility for parole was likely to be extended as there was a further warrant outstanding for non-payment of fine.

The deceased had been taking medication (Surmontel) for the past three years for depression and to control aggressive behaviour. Although he was prescribed these medications while in prison, the Coroner accepted that this was not as strong a dose as had been given before imprisonment. He had a prior history of suicide attempts and other members of his family have taken their own lives. The Coroner found that this information was not provided to the prison authorities and would not have been discoverable from prison records.

Shortly prior to his death, the deceased's de facto wife failed to visit. He was concerned that his wife was involved with another man and that she was about to leave him. Efforts to contact her by phone were unsuccessful. The Coroner found that this probably deepened any depression that [the deceased] had at the time, to the point where both prison officers and other prisoners were concerned for his well-being.

As a result, a prison officer requested the prison psychologist speak to the deceased, which occurred at about 5:00pm on 19 April 1995. As a result of the conversation and his assurances, the psychologist formed the opinion that the deceased did not present a threat to himself. It was arranged that the deceased would see a welfare worker on the following day and no arrangements were made for monitoring him.

At some time prior to lock down on the evening of his death, the deceased had written to his [de facto] wife indicating he intended to take his life. The letter was put in the mailbox at B Block movement control and located [when] the mail was cleared the following day. The deceased assured other prisoners he would be all right and he was locked in his cell at about 10.30pm. He was discovered hanging from a sheet near his cell door at about 12.40am.

'The deceased had taken a sheet from his bed and whilst standing on a chair near the cell door, he has fastened one end to the bars above the door and the other end around his neck. Resuscitation was unsuccessful and the deceased was transported to the Ipswich General Hospital where he was pronounced dead at around 1.50am.

Issues

The Coroner found the assessment that the deceased was not at risk, was made without regard to his medical file and there was no awareness of all the details in that file.

The Coroner found that there were no prison officers in the Block where the deceased was housed and the only monitoring was by an external patrol, who checked the prisoners through the external window approximately twice per night. This patrol found the deceased. The Coroner found that the intercom, which enables prisoners to communicate with the control office, was not switched on.

Members of the patrol had to run to the office of the operations manager to get the key to the safe in B block, then go back to B block and gain entry, open the safe, obtain the unit and safe keys from that safe, which finally allowed them access to the cell of the deceased. This situation renders implementation of the recommendation that resuscitation be attempted immediately upon finding a detainee apparently dead, impossible.

Recommendations

1. That anchor points should be covered in some way to prevent ties being made to them. (The Coroner pointed out that he had made a similar recommendation in relation to a death in custody in Rockhampton in 1988.)

2. There should be someone in attendance or a more effective monitoring system put into place during the hours of lock down in all cell blocks.

3. The intercom system should be upgraded so that it includes a fail safe backup to ensure it is open and monitored at all times and a system of checks to ensure that it is working at all times.

4. That there be a change to the security system in relation to the keys to cell blocks and cells, so as to make them more readily available should emergencies arise.

5. The medical or psychological staff have regard to all information available when making assessments on mental instability. If all information is not available at the time, then they should institute precautionary monitoring until they are able to have regard to all files.

Royal Commission Recommendations Breached

R95 Where motor vehicle offences are a major factor in imprisonment, programs to be consultatively developed to reduce incidence.

R152e Information exchange between prison and other medical services.

R152g(iv) Protocols for care and management of prisoners with a history of self-harm or disturbed behaviour.

R152g(vi) Protocols for care and management of prisoners who have a history of mental illness.

R152g(viii) Protocols for care and management of prisoners on medication.

R157 Securing of comprehensive medical history from outside. To accompany prisoner on transfers.

R158 Instruction to immediately attempt resuscitation on finding a detainee apparently deceased.

R165 Elimination/reduction of items with potential for self-harm.

Social Justice Commissioner

Comment

Offences such as dangerous driving, driving while unlicensed and fine default, for which the deceased was incarcerated, often attract diversionary sentences such as community service orders. Aboriginal people are more likely to attract prison terms for these offences instead of the alternatives. 28

The Queensland Government supported recommendation 95, that programmes be introduced to reduce offending where driving offences are a significant cause of incarceration. The Queensland Government has stated that no further action is to be taken on the recommendation, and that anecdotal evidence indicates that driving offences are not a significant cause of Aboriginal imprisonment. 29

Special provisions relating to Aboriginal prisoners were not followed as the deceased's Aboriginality was said to be not apparent from his appearance. Although there was a psychological assessment of the deceased, its adequacy is questionable if neither the deceased's Aboriginality nor medical history were taken into consideration. Judging a person's Aboriginality by appearance alone is unsatisfactory. It is likely that background information appeared on his prison admission screening form, exposing a deficiency in information flows. If there is no opportunity for self-identification at reception into prison, the form should be amended.

Additional Royal Commission Recommendations Breached

R7 State Coroner to investigate deaths in custody.

R92 Imprisonment as a last resort.

R95 Programmes to reduce offending in areas where Aboriginal people are frequently being imprisoned as a result of driving charges.

R121 Imprisonment not be automatically imposed for default on fine payments. Alternative sanctions be considered, and a statutory duty to consider capacity to pay.

R151 Aboriginal prisoners requiring assessment or treatment to be referred to a psychiatrist with knowledge and experience of Aboriginal persons.

R156 Aboriginal prisoners be subject to a thorough medical assessment at reception.

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79QLD

Male 32, died on 19 July 1995
Sir David Longlands Prison, Qld
Self-inflicted, Hanging

Coronial Inquiry Pending

Social Justice Commissioner

Circumstances of Death 30

The deceased was found hanged in his cell at around 2.30pm by a towel tied to the cell bars. He had been serving an eight month sentence for aggravated assault. According to a Corrective Services Spokesman 'foul play was not suspected'.

No further information is available at this stage.

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88QLD

Male 17, died 8 December 1995
Sir David Longlands Prison, Qld
Self-inflicted, Hanging

Coronial Inquiry Pending.

Social Justice Commissioner

Circumstances of Death 31

At approximately 12:35am, during a head count, the deceased 'was discovered hanging by a torn bed sheet from the louvres'. The deceased's cell mate was instructed to take the weight while the keys were fetched. This took some fifteen minutes.

CPR was commenced on arrival of a nursing sister. An ambulance was called and arrived at around 1:16am. It conveyed the deceased to the Princess Alexandra Hospital at 1:25am where he was 'pronounced life extinct' at approximately 2:00am.

Issues

The deceased was in a shared cell at the adult correctional centre after requests to be transferred from a juvenile detention centre. He was on remand for a charge of 'armed robbery with violence in company' and classified as a high security prisoner.

The deceased had made a telephone call to a female on the day before his death. The call apparently caused him some distress, although the contents of the conversation are unknown. At approximately 12:00am he had shown a letter to his cell mate who declined to read it (believed to be a suicide note). The deceased's 'cellmate had been unaware of the incident until he was woken by staff during the bed check'. 32

According to the Queensland Corrective Services Commission report, there had been no 'current indications' that the deceased was at risk as he had 'not been assessed as being at risk or requiring observations since August 1995'. When he was transferred to the adult prison 'he was assessed in [the] first five days and found not to be at risk'. This assessment 'was carried out by psychiatrists and counsellors, including Aboriginal counsellors'.

Following the death, 'formal debriefing sessions were conducted for all staff involved in the incident. Six other prisoners in the Unit where the deceased was housed were placed under observations as a result.

There are two major issues reportedly raised by this case:

1. It apparently took some time (allegedly fifteen to thirty minutes) to cut the deceased down as the keys to the cells are not carried by staff carrying out checks or head counts. The staff also refused to pass a knife through to the other prisoner so he could cut the deceased down. The fellow prisoner was required to take the deceased's weight for all that time.

2. That the deceased was a juvenile incarcerated in an adult gaol. Although this was said to have been the result of a request by the deceased, it is a breach of the Convention on the Rights of the Child. This should be the primary guide for authorities considering requests to be incarcerated with adults.

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90QLD

Male 23, died on 1 January 1996
Townsville Prison, Qld
Self-inflicted, Hanging

Coronial Inquiry Pending.

Social Justice Commissioner

Circumstances of Death 33

The deceased had been serving a twelve year sentence for armed robbery, deprivation of liberty and indecent assault. He had transferred to the Townsville Correctional Centre from a gaol near Brisbane shortly before his death.

The deceased hanged himself by a rope which he had apparently smuggled into his cell and tied to the ventilation shaft above the cell door. He was found by custodial officers at around 7:00am. Prison authorities are quoted as saying that the deceased had been 'checked on an hourly basis and nothing appeared to be wrong'. 34

No other information is available at this stage.


94QLD

Male 13, died on 9 March 1996
Townsville, Qld
Car Crash, Police Pursuit

Coronial Inquiry Pending

Social Justice Commissioner

Circumstances of Death 35

The deceased was a passenger of a stolen Commodore which was first noticed by detectives in a unmarked police car around 5:00am. Police started following the car allegedly after 'the driver ignored a direction to stop'. Police said 'the vehicle accelerated, skidded across the road and hit several small trees before stopping in the front yard of a house'.

Another passenger was seriously injured in the crash and had to be flown to Brisbane for emergency surgery. The driver, also aged thirteen, sustained minor injuries and is expected to be charged with a number of offences arising from the incident, including unlawful homicide.

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ENDNOTES

1 Per post-mortem report.

2 Tony Hewitt, Tension at Black Death Jail, The Australian, April 1990.

3 RCIADIC, Interim Report, AGPS 1988, p42.

4 The Coroner also noted that clauses 9.426(b), (c)(i), 464(a), 465, 467(a), (b), (h) of the Queensland Policeman's Manual were not complied with.

5 Race Discrimination Commissioner, Aboriginal and Torres Strait Islander Social Justice Commissioner Mornington Island Review Report Human Rights and Equal Opportunity Commission, April 1995 p3-12.

6 Behrendt J 'Prison as a Death Sentence: The Case of David Jason Barry' in Cunneen C (Ed) Aboriginal Perspectives on Criminal Justice, The Institute of Criminology Monograph Series, No 1, Sydney 1992.

1 Form 4 in Schedule 1 of the Coroners Rules 1959 is a report concerning the death by a member of the police force. It provides the medical practitioner conducting the post mortem or pathology examination with a context within which to assess the findings.

2 Tony Koch Courier Mail 21 July 1992.

3 Michael McKinnon 'Creek posse "like Klan"' Sunday Mail 25 July 1993 at 9

4 Fiona Kennedy 'CJC may probe drowning death' the Australian 26 July 1994 at 5

5 op cit

6 As stated in News articles cited at notes 1 and 2.

7 The coronial findings were very brief. The material in this profile comes from newspaper reports, which reported details of the QCSC's internal investigation, and An Agenda for Action: The First Report of the Aboriginal and Torres Strait Islander Overview Committee August 1996 p 121-125.

8 Tony Koch, 'Agencies Stall Inquiry: Coroner', Courier Mail, 4 December 1992, p.11.

9 Counsel made an application to have the Internal Queensland Corrective Services Commission report produced to the Coroner on the morning of the preliminary hearing. Days were spent in legal argument, firstly over production to the Coroner, the QCSC maintaining it was protected by secrecy provisions of its enabling legislation, and secondly, once that question was resolved in favour of the family of the deceased, over the extent of publication of the document. The QCSC lost that argument as well, and sought judicial review in the Queensland Supreme Court. On the eve of the review the QCSC abandoned it.

10 'Hanging Report Blasts Officers,' Courier Mail, 24 February 1994, p5.

11 The deceased was an extremely accomplished painter. One of his paintings appears on the cover of the first report of the Queensland Aboriginal and Torres Strait Islander Overview Committee, August 1996.

12 See RCIADIC Report of the Inquiry into the Death of Walter Barney December 1990.

13 Courier Mail, 12 April 1994.

14 Courier Mail 8 March 1994, p 7.

15 For a history of Musgrave Park see RCIADIC, Regional Report of Inquiry into Queensland, AGPS 1991 p259-263.

16 An Agenda For Action: The First Report of the Aboriginal and Torres Strait Islander Overview Committee August 1996 p 35

17 Queensland Government Progress Report on Implementation, December 1994 p242.

18 From a report on the Inquest so far by Counsel representing the family.

19 M. Hall, Aborigine Commits Suicide in Prison Cell, Townsville Bulletin, 5 July 1994, p 1.

20 M. Steene, Watch-house 'Not Told Prisoner was Suicidal', Townsville Bulletin, 7 July 1994, p 1.

21 from newspaper reports at the time of death.

22 For an example of the comparative likelihood of an Aboriginal person accused of a driving offence being sentenced to prison, home detention or a community service order see NT Department of Correctional Services 1994/95 Annual Report, p 71, 80, 81.

23 Queensland Government Progress Report on Implementation December 1994 p250.

24 information taken from Courier Mail article, 20 July 1995

25 Information taken from Qld Corrective Services Commission official briefing note on the death.

26 Courier Mail 9 December 1995 quoting Prison spokesperson.

27 Aboriginal Deaths in Custody Watch Committee Press Release 2 Janaury 1996

28 Courier Mail, 3 January 1996 at p. 2

35 Account taken from Sunday Mail Newspaper 10 March 1996

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A Report prepared by the Office of the Aboriginal and Torres Strait Islander Social Justice Commissioner

for the

Aboriginal and Torres Strait Islander Commission