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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


Western Australia

2WA 11/7/89 46

M

Police Port Headland Lockup Natural
15WA 5/4/90 15

M

Police Tonkin Hwy, Wattle Grove Injury
16WA 5/4/90 14

F

Police Tonkin Hwy, Wattle Grove Injury
17WA 5/4/90 17

M

Police Tonkin Hwy, Wattle Grove Injury
23WA 25/1/91 35

M

Prison Canning Vale Prison Natural
24WA 19/2/91 16

M

Police Mitchell Fwy, Perth Injury
33WA 17/12/91 21

M

Prison Greenough Regional Prison Self-inflicted
35WA 20/1/92 13

M

Police Edward Road, Carmel Injury
56WA 22/1/94 30

M

Prison Canning Vale Prison Drugs
57WA 25/1/94 34

M

Prison Greenough Regional Prison Natural
65WA 14/9/94 37

M

Police East Perth Lockup

Natural

Natural
85WA 29/10/95 46

M

Prison Broome Regional Prison Natural
86WA 4/11/95 17

M

Police Thornlie, Perth Injury
89WA 9/12/95 27

M

Police Halls Creek Injury
95WA 27/4/96 22

M

Prison Canningvale Remand Centre Self-inflicted

 

2WA

Male 40, died on 11 July 1989
Pt Hedland Police Lockup, WA
Heart Attack

Coronial Inquiry By Coroner W G Tarr SM

Finding handed down 28 November 1989

Finding

The death was the result of coronary atherosclerosis. There is no evidence which creates any suspicion that there was a causal link between the deceased being held in custody and his death.

Summing up

Circumstances of Death

The deceased was arrested some time after 1:00pm after being found staggering in the middle of a roadway in a drunken condition. He was charged with being found drunk and placed in the women's section of the Lockup with one other prisoner who had previously been arrested for an alcohol related offence. There was also another inmate also at the time who was allowed freedom within the male cells and the main exercise yard.

The Coroner found that there were regular hourly checks of the deceased in his cell and the exercise yard. On one occasion a physical check at cell level was made when all three prisoners were not visible from the police station office.

The deceased was expected to be released following his evening meal, which was served at around 6:30pm. At approximately 6:45pm, the deceased was found collapsed in the shower/toilet enclosure by the Police Aide who called 'the acting officer-in-charge and another constable'.

The Coroner noted that resuscitation was not attempted because it was the opinion of both officers that the deceased had been dead for some minutes, and that resuscitation was therefore not appropriate. A doctor from Pt Hedland Regional Hospital was called and certified life extinct.

Issues

No significant issues identified by Coroner.

Recommendations Nil

Royal Commission Recommendations Breached Nil

Social Justice Commissioner

Comment

The criticisms made in the Royal Commission Interim Report of cursory coronial inquiries were not taken into consideration when conducting the Inquest. It was said that coronial inquiries needed to be more than a 'part-time function of frequently overworked magistrates'. 1 The findings of inquest were two pages long, without recommendations. The Interim Report had been released for some months at the time of this death. There was no mention by the Coroner of the findings of Commissioner Muirhead or the Recommendations contained in the Report relating to the policing of drunkenness and the need for alternatives to care for and treat intoxicated persons. The circumstances illustrate the inappropriateness of detaining intoxicated persons in police cells without medical screening and where medical care is unavailable.

The failure to attempt resuscitation was not commented on by the Coroner. The decision not to attempt resuscitation because the deceased had apparently been dead for some minutes revealed an incomplete understanding of resuscitation and the chances of reviving unconscious detainees.

Additional Royal Commission Recommendations Breached

IR 44 Functions and status of coroner urgently examined and re-assessed with recognition of importance of Coroner's role.

R7 Specific State/Territory Coroner for inquiries.

R12 Requirement that coroner examine quality of treatment and supervision prior to death.

R13 Coroner to make recommendations to prevent further deaths.

R79 Abolition of offence of public drunkenness (IR3)

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

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

R87 Police to apply arrest as a final sanction (IR8, IR9).

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

R126 Completion of screening form and risk assessment by a trained person to precede placement in a cell.

R137 Regular checks of detainees in cells, more frequent for detainees at risk (IR15).

R158 First priority on finding a person apparently dead to be resuscitation and medical assistance. [IR45]

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15WA

Male 15, died on 5 April 1990
Tonkin Highway Wattle Grove, WA
Injuries in Car Accident, Police Pursuit

Coronial Inquiry Finding handed down November 1991

Coroner DA McCann

Findings

The deceased died as a result of multiple injuries, by way of accident.

Summing Up

Circumstances of Death

The deceased was the driver of a car which had been taken the previous night from a motel unit. At about 3:00am, the car was observed by police travelling at excessive speed and suspicions were raised that the occupants had been involved in a robbery. After a high speed chase lasting some fifteen minutes, the deceased drove through a red light (at a speed judged to be in the vicinity of 220kph) and crashed into a car proceeding through the green light.

Issues

It was considered that 'the death arose by way of Accident', that 'in a sense it was without regard to the consequences and heedless of the danger', so it was 'reasonable to suppose that the deceased had not formed a specific intention to collide with any other vehicle'. Two passengers (cases 16WA and 17WA) and the occupant of the other car were also killed in the crash. The Coroner found that those deaths 'arose by way of Unlawful Homicide'.

The Coroner rejected any claim that the 'police officers acted unreasonably in pursuing the vehicle in question', considering that they 'must attempt to uphold the law, exercising a reasonable discretion in doing so'.

The Coroner considered that the deceased was an infant 'for the purposes in hand' and that the Inquest should 'inquire into all circumstances as may throw light on the treatment and condition of the infant before death'. He noted the number of previous offences which the deceased and his companions had already committed and the opportunities which had been provided for their rehabilitation.

The Coroner also considered that 'the parents and guardians had failed to exercise effective control over the three young people who died [although] there is evidence that some at least tried'. Office of the Department for Community Services were also criticised for failing 'to divert the young people � into a constructive way of life'.

Recommendations

These recommendations were made in common with the other deaths in this accident:

1. That there be 'early detection and bringing alleged offenders before the Courts' to dissuade [others] from committing crime in the first place; and

2. That 'young persons who have failed to comply with orders of the Children's Court �be brought back before the Court promptly if they fail to comply with such orders.'

Royal Commission Recommendations Nil

Social Justice Commissioner

Comments

The Coroner noted the 'reading of�reports of the Royal Commission�provides a sad and salutary exposure of the past lives of Aboriginal children in this State'. However, there were no references to the Interim Report.

The Coroner suggested that prompt dealings by the Courts will lead to 'persons being dissuaded from committing offences in the first place'. Evidence from the Royal Commission's investigations, however, suggest that early contact with the Courts has little effect on the behaviour of Aboriginal young people and in fact establishes a pattern of institutionalisation or imprisonment which is difficult to break.

The risks and danger of high speed car pursuits involving young people is well documented. High speed car chases should be banned where children or young people are drivers or passengers of the vehicle.

Additional Royal Commission Recommendations Breached

R 60 Elimination of, and disciplining for, rough police treatment of Aboriginal persons.

R 95 If motor vehicle offences are a major factor in Aboriginal imprisonment, programs should be developed to reduce the incidence of such offences.

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16WA

Female 14, died on 5 April 1990
Tonkin Highway Wattle Grove, WA
Injuries in Car Accident, Police Pursuit

Coronial Inquiry (See15WA)

Finding

The death arose as a result of unlawful homicide and was caused by multiple injuries sustained when a stolen car being pursued by police crashed into another vehicle.

Summing up

Circumstances of Death

The deceased was the passenger of the car driven by the deceased in case profile 15WA. See that profile for further information.

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17WA

Male 15, died on 5 April 1990
Tonkin Highway Wattle Grove, WA
Injuries in Car Accident, Police Pursuit

Coronial Inquiry (See15WA)

Finding

The death arose by way of unlawful homicide and was caused by multiple injuries sustained when a stolen car being pursued by police crashed into another vehicle.

Summing up

Circumstances of Death

The deceased was the passenger of the car driven by the deceased in case 15WA. See that profile for further information.

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23WA

Male 35, died on 25 January 1991
Canning Vale Prison, WA
Heart Attack

Coronial Inquiry Coroner David McCann SM

Finding handed down on 22 October 1991

Finding

The death was a result of coronary atherosclerosis with recent myocardial infarction.

Summing up

Circumstances of Death

The deceased had a history of incarceration for property offences, driving offences and fine default, appearing in Children's Court aged nine and serving his first sentence of imprisonment when he was fourteen. He had recently been transferred to Canning Vale Prison from Fremantle Prison on the recommendation of the Prison Medical Services director after recommendations following his health assessment. He had suffered from and been treated for a number of health problems, such as pancreatitis and epigastritis, during his prison terms. He was a diabetic.

For two weeks prior to his death, the deceased had complained to prison staff, prisoners and others of chest pains. He saw a medical officer four days prior to his death. He was heard to complain of chest pains in the waiting room, but the doctor gave evidence that the deceased complained of constipation and stomach pain. The symptoms were considered to be associated with his previous illness.

The deceased apparently 'expressed dissatisfaction' to prison officers and prisoners with the response of hospital officers to his complaints. He told his sister he wanted a visit from the Aboriginal Medical Service. An officer who overheard him advised that he request the Aboriginal Prison Visitor Scheme to arrange an appointment. On the morning of 25 January 1991 the deceased collapsed, hitting his head while collecting some pencils for the Education Unit. Resuscitation failed to revive him and an autopsy showed a heart attack had occurred some one or two days earlier.

Issues

The Coroner considered that the 'medical attention given to the deceased was generally appropriate.' He concluded however 'that the deceased had no confidence in the Prison Medical Service' and thus had 'refrained from raising his real concerns with [the medical staff]'. He found that on balance the fact of incarceration was not a significant factor in the death and 'he was at equal risk of a fatal heart attack if he was confined in prison or was living in the community'.

Recommendations Nil

Royal Commission Recommendations Breached Nil

Social Justice Commissioner

Comment

A number of Aboriginal prison deaths from undiagnosed heart disease have involved prisoners who had recently seen a doctor.

The ALS were very critical of the health care and information flows, the adequacy of the screening procedures and the medical records kept. The Coroner did not address these specific issues in making the finding that medical attention was adequate. He found that the deceased had failed to communicate the true nature of his complaint to medical officers, despite having done so to many of the other witnesses at the inquest. He speculated that lack of faith in the medical service may have been a cause.

Medical staff should be better apprised of, and sensitive to, effective communication with Aboriginal people. Staff should be trained so that they are more knowledgeable about, and can recognise symptoms of 'lifestyle' diseases such as heart disease and diabetes among Aboriginal people.

The finding that the deceased was at equal risk had he been in the community is undermined by the fact that he was in the process of attempting to secure a visit from an independent medical practitioner at the time he died. The Coroner addressed this issue by saying that 'the absence of freedom of choice is� the real sanction for behaviour which is not acceptable to society'. This statement is wrong in law - denial of access to medical care can amount to criminal negligence.

The case illustrates the need for an independent complaints system in prisons, and one which includes health care complaints. Given literacy levels among inmates complaints systems should be as informal and accessible as possible, but at the same time responsive and carefully documented. Prisoners should be able to contact Aboriginal prison visitors by telephone rather than having to wait for visits in cases such as this.

Additional Royal Commission Recommendations Breached

R13 Coroner to recommend ways to prevent further deaths.

R127d Local rules to ensure medical services to those in custody when the need arises.

R150 Standard and range of health care of persons in correctional institutions to be the same as for the general public (In the case of Aboriginal prisoners this includes access to specific Aboriginal Health Services).

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

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

R176 Establishment (and functions) of an independent Complaints officer for each prison, to be responsible to the Ombudsman or Minister for Justice.

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24WA

Male 16, died on 19 February 1991
Mitchell Freeway, Perth, WA
Injuries in Car Accident, Police Pursuit

Coronial Inquiry Coroner D A McCann

Finding (on Inquiry) handed down 20 February 1992

Findings

The death was a result of chest and abdominal injuries which arose by way of unlawful homicide.

Summing Up

Circumstances of Death

The deceased was a passenger in the rear seat of a stolen Commodore which has being pursued by police at about 3:00am on the Mitchell Freeway. The vehicle then attempted, at high speed, to exit the Freeway, but collided with a steel guard rail and rolled several times.

The deceased was injured in the collision and died soon after being admitted to the Royal Perth Hospital.

Issues

The Coroner noted that the driver of the stolen vehicle was convicted in the Perth Children's Court of the offence of unlawful killing in respect of the death of the deceased. He chose not to conduct an inquest into the matter.

Recommendations Nil

Royal Commission Recommendations Breached Nil

Social Justice Commissioner

Comments

The Coroner accepted the police brief in this matter without holding an inquest, on the grounds that the driver was charged with an indictable offence. As a result there was no scrutiny of the decision to commence the pursuit, or the manner in which it was conducted. Police denied witness reports that up to eight police cars were involved, indicating that only two marked traffic cars and one unmarked car took part in the chase. 2 The number of young Aboriginal people dying in high speed pursuits by police in Western Australia (eight between May 1989 and May 1996) suggests that police pursuits should be more thoroughly investigated to find a means of preventing similar deaths.

The late Rob Riley commented that 'it is inevitable that something will go wrong. The very fact that the police officers are skilled operators with advanced driving skills and the kids don't have control over the vehicle is enough to cause an accident'. 3 More understanding of the 'sub-culture' which supports young people who engage in car theft and high speed chases is required. The risks and danger of high speed car pursuits involving young people is well documented. High speed car chases should be banned where children or young people are drivers or passengers of the vehicle.

Additional Royal Commission Recommendations Breached

R11 Legal requirement for public coronial inquiry into all deaths in custody.

R12 Legal requirement that Coroner's inquiry cover how the person was treated before death.

R13 Coroner recommend ways to prevent further deaths.

R35 Police investigations inquire into the arrest or apprehension and thoroughly examine the scene of death and forensic exhibits.

R60 Elimination of, and disciplining for, rough police treatment of Aboriginal persons.

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

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33WA

Male 21, died on 16 December 1991
Greenough Regional Prison, WA
Self-inflicted, Hanging

Coronial Inquiry Coroner Wheeler at Geraldton Coroner's Court

Finding handed down 4 November 1992

Findings

The deceased hung himself in his cell at Greenough Regional Prison. The death occurred by asphyxiation. The Coroner returned an open finding as to the deceased's intent and purpose in hanging himself.

Summing Up

Circumstances of Death

The deceased was arrested on 11 December and charged with assaulting his pregnant sister. He was refused bail before a Justice of the Peace. He was remanded in custody to Greenough Regional Prison from Meekatharra. Meekatharra police gave evidence at the inquest that the deceased had taken an over-dose of anti-depressants (Tripinol tablets mixed with beer) when he was transferred. It was not a fatal dose. He was taken to Geraldton Hospital. Nurses from the Hospital gave evidence that they had suggested he remain in hospital and be monitored. He was taken back to prison when he became agitated, and was kept under observation. The Coroner found that the deceased seemed to be in 'good shape' over the next few days considering the overdose, and gave no indication of distress to prison staff. However, the Coroner noted that he was depressed. During a phone call to his aunt on 17 December 1991, he told her he would hang himself if he was convicted on the assault charge. She did not pass this information to prison staff or the ALS solicitor, although she asked that the date of his hearing be brought forward.

During the lock up for lunch on 19 December, the deceased took his belt and fashioned a ligature. About an hour after the lock up began, he was found by prison officers hanged from the cell cross bar. An emergency knife, kept for such purposes, was used to cut through the belt and officers attempted resuscitation.

Issues

The Coroner found that putting the deceased in observation clothing on his return to prison from the hospital 'was simply a formality', something the prison did on 'automatic pilot'. The Coroner found he was not considered a suicide risk at that stage.

The coronial findings are very unclear about the date for the deceased's next court appearance. It appears that a date for a bail application was set down for the day of his death, although the ALS solicitor was unaware that he had an appearance on that date. The deceased had apparently thought at different times that the appearance was on the Monday, the Tuesday and the Friday. The transcript of the findings is unclear about certain requests from the deceased's aunt which led the ALS solicitor to take steps to expedite the deceased's appearance before the court.

The Coroner found that the deceased felt abandoned because his family had ceased contact with him. He believed he was going to be convicted to a one year prison term, and did not want to go back to gaol over what he felt was a matter to be sorted out in the family.

The question of whether the deceased actually meant to kill himself was dealt with at some length by the Coroner. A number of explanations were considered, including that the deceased wanted to strengthen his position for bail or to get attention from his family so they would drop the charges. On the other hand he was extremely distressed about his treatment by his family and 'put in a fairly professional effort at making the noose'. At the suggestion of counsel for the family, the Coroner made an open finding as to the deceased's intent to kill himself.

The Coroner praised the attempts by an experienced paramedic and a trained nurse to resuscitate the deceased.

Recommendations Nil

Royal Commission Recommendations Breached Nil

Social Justice Commissioner

Comments

One of the issues raised by this death is counselling to the families of the people who have died in custody. The deceased's brother also hanged himself in custody at the Geraldton Lockup on 8 June 1988. This was the subject of an investigation by the Royal Commission 4 and had sparked a riot in Geraldton.

The assessment on return to prison was reportedly that the deceased was not a suicide risk. He was therefore not subject to increased observation or regular checks. According to the Coroner's findings he had been alone for about an hour before he was found. The Coroner did not discuss in detail the fact that the deceased had recently been hospitalised for an overdose, or the extent to which psychiatric or welfare support was available (R12). He did point out the evidence of the nursing staff at the hospital that the preferred option was to keep him in hospital with monitoring. There was no examination of the assessment procedures the deceased's return to prison. There is a strong argument that he should at least have been put in a cell with another prisoner. There is also a question as to why, in the circumstances, he was allowed to have a belt.

The distinct 'at risk' clothing was one of a number of interdependent safeguards put in place to reduce the risk of self-harm. The use of one safeguard without the related measures, such as closer observation, gives ambiguous messages to staff about what procedures thay should adopt in relation to a suicidal inmate. It indicates that officers did consider the deceased to be at some degree of risk.

The Coroner made no recommendations to prevent further deaths (R13). An action for negligence has been filed in relation to this death. A negligence action has also commenced in relation to the death of his brother.

The deceased's application for bail was refused by a Justice of the Peace and his case was to have been heard by a Justice of the Peace in Meekatharra. This is in clear breach of Royal Commission recommendation 98. However, he was transferred to the Geraldton Magistrates Court due to other charges.

Additional Royal Commission Recommendations

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

R13 Coroner to recommend ways to prevent further deaths.

R98 Where not already done, phasing out of use of Justices of the Peace to determine charges or impose penalties.

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

R126 Careful completion of screening form and risk assessment by a trained person to precede placement in a cell.

R151 Referral of Aboriginal prisoners/detainees for psychiatric care.

R152g(ii) Protocols for care and management of prisoners who have drug related conditions.

R152g(iv) Protocols for care and management of 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.

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35WA

Male 13, died on 20 January 1992
Carmel, Perth, WA
Injuries in Car Accident, Police Pursuit

Coronial Inquiry D A McCann SM

Reported on 9 June 1992. A full inquest was not held

Findings

Coroner found that the deceased died at the intersection of Edward Road and Gilchrist Road as a result of a head injury, and that the death arose by way of unlawful homicide.

Summing Up

Circumstances of Death

The deceased was a passenger in a stolen car being driven at high speed. They were noticed by police and pursued until they crashed. Two police vehicles with sirens sounding were involved in the pursuit.

The Coroner reported that the driver approached the intersection at excessive speed and was unable to negotiate the 90 degree right hand bend. The driver lost control and the car slid sideways and collided, passenger side on, with a power pole.

Issues

The driver was convicted on 10 April 1991 in the Perth Children's Court of unlawful killing in respect of the death of the deceased. The Coroner decided not to hold an inquest into the matter.

Recommendations Nil

Royal Commission Recommendations Breached Nil

Social Justice Commissioner

Comments

The coroner accepted the police brief in this matter without holding an inquest on the grounds that the driver was charged with an indictable offence. As a result, there was no scrutiny of the decision to commence the pursuit, or the manner in which it was conducted. The deceased was a thirteen year child who had received his first conviction at the age of nine.

The risks and danger of high speed car pursuits involving young people is well documented. High speed car chases should be banned where children or young people are drivers or passengers of the vehicle.

Additional Royal Commission Recommendations Breached

R7 Specifically designated State/Territory Coroner for Inquiries of custodial deaths.

R11 Legal requirement that all deaths in custody are subject to Coronial inquiry and Inquest.

R12 Coronial inquiries into the treatment and care of the deceased prior to death.

R13 Coroner recommend ways to prevent further deaths.

R35 Police investigations inquire into the arrest or apprehension and thoroughly examine the scene of death and forensic exhibits.

R60 Elimination of, and disciplining for, rough police treatment of Aboriginal persons.

R95 If motor vehicle offences are a major factor in Aboriginal imprisonment, programs should be developed to reduce the incidence of such offences.

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56WA

Male 30, died on 22 January 1994
Canning Vale Prison, WA
Drug overdose

Coronial Inquiry D A McCann

Finding handed down 28 July 1995

Findings

The deceased died as a result of acute opiate toxicity and the death arose by way of unlawful homicide.

Summing Up

Circumstances of Death

On the night of his death the deceased was part of a group of prisoners who were consuming heroin smuggled into the prison by a visitor. He had apparently 'begged a fellow prisoner' for an injection of the drug which turned out to be a very high grade of purity. The deceased had been unable to inject himself and the drug was administered by another inmate who was consequently charged in relation to the death.

A muster check was made of the inmates at about 6:30pm and a prison officer recalled having a conversation with the deceased who 'appeared to be his normal self'. After taking the drug around 7:30pm, the deceased went to the cell of another prisoner and lay down on the bed. With time approaching for 'lock down', the occupant became worried when he could not rouse the deceased and called another inmate to help carry the deceased to his cell.

The deceased was placed on his bed in an upright position and was observed by guards who secured the cell. The condition of another inmate who was also badly affected after taking the heroin (eyes rolling and breathing difficulties) was noticed and he was taken to the infirmary and given an injection to counteract the effects.

The Coroner found that other checks were carried out by shining a light through the door grill, but failed to show anything 'out of the ordinary'. When the duty officer heard a noise in the cell block at about 6:00am he found the deceased with froth coming from his nostrils. The nurse was summonsed from the medical centre examined the deceased and found he had no pulse, his pupils were fixed and dilated and rigor mortis had set in. Resuscitation was not attempted and the deceased was declared dead.

Issues

Evidence at the Inquest and the later trial for manslaughter, was that drugs (heroin, cannabis and 'pills') were widely available in the prison. On this occasion the drugs were passed by mouth from the visitor when she kissed a prisoner goodbye. The drugs were intended for another inmate held in a high security cell and after taking some of the powder for himself, the prisoner who received it, passed the drugs on to 'whom it was intended'.

The prisoner who smuggled the drug and administered the fatal injection was charged with unlawful homicide. He was found guilty and sentenced to an additional four years for manslaughter and heroin related offences.

The 'code' among prisoners 'not to inform on each other to prison officers' was found by the Coroner to be a contributing factor. Despite the fact that a prisoner was being treated for an overdose, he refused to name others involved. The Coroner found it was 'understandable' that the other prisoners would conceal the deceased's condition from prison staff.

While it was not practicable to train prison officers to detect that inmates might be under the influence of a drug, the Coroner held that they were trained to observe inmates and to note any abnormal behaviour. A prison officer did note the unusual behaviour of one of the prisoners, reported the matter and requested other prison officers to pay particular attention, and saved that prisoners life.

The Coroner considered that the muster checks have both a security element and a welfare element but rejected submissions that a complete and thorough check of inmates be made if suspicions were aroused that others may be under the influence of a substance. He believed that any further step in monitoring the condition of inmates would require a far greater intrusion into the privacy of inmates and would be difficult to justify.

The Coroner also noted that it was the policy of the prison authorities not to provide methadone within the prison system, with some particular exceptions which were not applicable in this case.

Recommendations Nil

Royal Commission Recommendations Breached Nil

Social Justice Commissioner

Comments

The deceased was separated from his family when he was six weeks old and placed in Marribank mission. He then lived in various foster situations and later detained in a number of juvenile detention centres.

The pathology report commented that 'the blood morphine and codeine concentrations are consistent with observed post mortem blood morphine and codeine concentrations determined on eleven fatalities involving recent use'.

The frequency and quality of the checks carried out on prisoners is another issue of concern. The deceased was checked only once in a twelve hour period.

Additional Royal Commission Recommendations Breached

R174 Employment and location of Aboriginal Welfare Officer by Corrective Services

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57WA

Male 34, died on 25 January 1994
Geraldton Regional Hospital, WA
Natural, Heart Attack

Coronial Inquiry Coroner R K Black SM

Finding handed down on 17 November 1995

Findings

The death was a result of a cardiac arrest consequent upon an acute myocardial infarction and arose as a result of natural causes.

Summing Up

Circumstances of Death

The deceased had been incarcerated in Greenough Regional Prison prior to transfer to the Geraldton Regional Hospital. On 20 January 1994, the deceased was seen by a nurse at the prison. He had complained of central chest pain that lasted approximately three minutes, of feeling faint and generally feeling unwell and said 'he felt funny in the chest'. Nothing unusual was found, given his pre-existing medical condition, which included hypertension and diabetes, and he was prescribed paracetamol.

The deceased attended the clinic conducted by a medical practitioner the following day. He was observed to be coughing and expectorating yellow sputum. An antibiotic was prescribed. That evening one of the nurses was telephoned at her home by a prison officer regarding the deceased, who had called on the cell alarm. It appears there was no medical presence at the prison at the time. He was 'apparently suffering from pains to the central/left chest area'. The advice was to take the deceased to hospital which was done by ambulance at approximately 9:05pm.

The deceased was examined in hospital by the prison medical practitioner, which included an ECG, and was diagnosed as suffering from oesophagytis and given an antacid. Following his discharge back to prison, he received no further treatment over the weekend and on morning sick parade on 24 January again complained of feeling unwell. The nurse arranged for him to rest until the doctor's clinic operated that afternoon. At around 1:30 that afternoon, the nurse was called to the deceased's cell where she observed the deceased to expectorate pink sputum. The deceased then expressed some fear of dying in prison. At the nurse's suggestion, he was assisted to the sick bay to await the doctor.

When the doctor arrived, the deceased was observed to be very unwell - short of breath, cold, clammy and in obvious distress. He was admitted to hospital at approximately 3:30pm. The attending physician's report noted that the deceased 'has had a recent lateral myocardial infarction', but that 'the degree of ventricular failure however is somewhat difficult to determine'.

The deceased was treated with various medications and visited by the prison doctor. He remained hospitalised overnight and 'observed regularly'. Following a review of his condition at 8:30am the next morning, arrangements were made to transfer the deceased to Perth via the Royal Flying Doctors Service. At around 10:50am, however, the deceased developed serious ventricular fibrillation. He was treated by way of DC chock and adrenaline and intubated, ventilated and CPR was commenced. The resuscitation was not able to be maintained and life was pronounced extinct at 11:43am.

Issues

The Coroner noted that the deceased was in a high risk category with regard to suffering coronary artery disease, the indicators being: Aboriginal descent, non-insulin dependent diabetes melitis, a history of hypertension, obesity, and the fact that he was an alcoholic and a smoker. While the prison authorities were aware of his condition, they were not aware of the treatments which the deceased had received prior to his incarceration or during other times of incarceration as not all medical records were disclosed or made available.

Recommendations

Insightful comments were made by the Coroner with regard to the need for access to confidential medical information about prisoners, including previous medical history, and when transferring prison medical files when prisoners are hospitalised:

1. At the time of admission to prison during the initial medical check, prisoners be invited to sign release forms in relation to medical history 'directed to any and all medical practitioners he has been treated by' (although this should not be compulsory with prisoners able to decline.)

2. Medical files kept at the Prison Health Service to be sent with prisoners when they are transferred to or being treated at a hospital. To address the issue of confidentiality, the file should be sealed so the prisoner and accompanying prison officers do not have access to it, and returned in the same manner when the prisoner is discharged or no longer being treated in hospital.

Royal Commission Recommendations Breached

R152e Information exchange between prison and other medical services

R152g(ii) Protocols for care and management of prisoners who have drug related conditions.

R153b Confidentiality issues between prison staff and prisoners to be addressed.

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

R154b Prison medical services staff to be trained in Aboriginal health issues.

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

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

Social Justice Commissioner

Comments

The Counsel assisting the next of kin on instruction from the ALS (WA) made application to the Coroner that 'two police officers� explain the absence of proper investigation'. 5 The ALS (WA) expressed concern at 'an almost total absence of investigation procedures following the death'. The application was refused on the basis that the Coroner was satisfied that the initial investigation was adequate.

The concerns expressed by the Coroner in relation to the desirability of having appropriate information about prisoner health and medical history are endorsed. The requirement that medical attention provided while in custody be of a standard which the general community enjoys includes access to medical histories to ensure an accurate diagnosis can be made.

Additional Royal Commission Recommendations Breached

R7 Specific State/Territory Coroner or designated coroner for deaths in custody inquests.

R8 Development of specific rules for inquiries and inquests.

R36 Investigations into deaths to be structured to provide a thorough evidentiary base for coroner's consideration into the cause and circumstances of death, and the quality of care, treatment and supervision of deceased prior to death.

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65WA

Male 37, died on 14 September 1994
East Perth Lockup, WA
Heart and Liver Disease

Coronial Inquiry Coroner Richard Bromfield at Perth Coroner's Court

Inquest yet to be completed

Social Justice Commissioner

Cause of death

It was agreed at the inquest that the cause of death was heart failure in a man with pre-existing heart disease, to which alcohol withdrawal was a contributing factor.

Circumstances of Death 6

The deceased had been arrested on a warrant as part of a 'routine patrol' by police at Weld Square, a place well known to be frequented by Aboriginal people.

He was a quietly spoken traditional person who was at times extremely difficult to understand. English was his second language. During the admission procedure at East Perth Lockup he told the officer on duty something about being on blood pressure medication. The officer noted blood pressure medication on the admission form. He answered 'yes' to a question about chest pains, which was also recorded on the form. He advised that he had headaches and drank seven days a week. No further inquiries were made. The officer subsequently assessed the deceased's health as 'OK'. He told another prison officer that he had been recently hospitalised for a leg problem. None of this information was conveyed to the officer-in-charge or the welfare sergeant.

The deceased was held over night in East Perth Lockup. Although he did not tell the officer that his medication was at the night shelter, visitors from the Aboriginal Visitor's Scheme noted this in the Visitors Book at the Police Station. Police did not become aware of this information until after the death, as there was no procedure for examining the Visitors Book.

Fellow prisoners gave evidence that the deceased was vomiting throughout the night and during the breakfast and exercise periods, was weak in the shower, and had to sit on the floor to take his trousers off. The evidence indicates alcohol withdrawal. Police stated that they received no complaints from the deceased.

Prior to and after appearing in court the deceased complained of feeling unwell and was observed vomiting and dry-retching. Medical assistance was not sought or provided. The deceased collapsed in a cell at midday. After a delay, he was given resuscitation and was transferred to hospital in the early afternoon. He was certified dead approximately two hours later at 2:17pm.

Issues

The deceased was a Aboriginal man from a remote community in the north-west of the state. He had been through the law and had a considerable degree of status in his community. On leaving his community and coming to Perth he was dislocated from his family and community. Literacy problems and shyness meant that he had difficulty accessing services. He had longstanding health problems associated with alcohol abuse.

The deceased had an extensive police record, mostly relating to drunkenness and vagrancy. On this occasion he was sitting with a group of Aboriginal people in Weld Square, a park known as a gathering place for the community. He was not offending at the time, but police ran a warrant check on the group and found an outstanding warrant for the deceased. The greater scrutiny on Aboriginal people who are either not offending or offending in a very minor way by park drinking can amount to unlawful discrimination and police harassment. (R80, 83, 84, 88, 214, 215, 220, 221, 223). 7

Evidence was given that police responded to complaints from local businesses by placing a directive on the police bulletin board that officers include the park in their patrols (R87b). 8 The Royal Commission called for consultation with Aboriginal people and organisations about appropriate policing in cases such as this, and cultural training for police officers.

The risk assessment procedures at the lock up were criticised by the Aboriginal Legal Service. There was no record that the deceased was intoxicated (R122, 126, 131, 138). Police were notified of the fact that he required medication and was experiencing chest pains, details recorded on the risk assessment form, but no follow up procedures were put in place (R122, 126, 127f(i), 127f(ii), 127f(vii), 133, 137, 138, 161). The information was not conveyed at the change of shift (R132). Information from the Aboriginal Visitors Scheme that the medication was at the shelter was disregarded (R145). Police guidelines for working with the Aboriginal Visitors Scheme were apparently never drawn up. A doctor from the Aboriginal Medical Service told the Coroner that it would have been 'difficult to establish his health status or potential risk in custody because of his shyness and reserved nature� typical of North-West Aborigines'. The death illustrates the desirability of the Aboriginal Medical Service providing health services at this and other lockups (R148).

Prisoners gave evidence that there was a delay in the police officers commencing resuscitation. The prisoners were removed from the cell before resuscitation commenced. No resuscitation equipment was available close to the holding cell (R158, 159, 160). Although there was a nursing post, it was only staffed 10:00am - 3:00pm Thursdays, Fridays and Saturdays. There were no nursing staff on duty on the Monday and Tuesday when the deceased was held. The Royal Commission noted the need to improve conditions at the East Perth Lockup (R148). 9

A Senior Magistrate has severely criticised the East Perth holding cells adjacent to the court complex, 10 saying that they are 'demeaning.' He called for them to be closed, and noted that the deceased in this case had died 'between the time the man was fined and the time he was due to be released downstairs'. About an hour had elapsed since he was given the fine and became due for release.

The West Australian police union secretary commented in the press that 'it is totally unreasonable for police who catch the crooks to them be accountable for their welfare'. 11 The statement indicates that police have very little understanding of their duty of care. When a choice is made to arrest, other avenues of assistance are removed. Police place themselves in the position of being the only ones able to provide care. Failure to provide assistance can be a criminal offence. 12

There were also problems with the post-death investigations. There was no protocol for the notification of the Aboriginal Legal Service in the event of a death in custody (R20). There was a delay in appointing counsel assisting, which meant that counsel assisting had no input into the investigation (R26, R28). There was inadequate notification of the family or the Aboriginal Legal Service of the post mortem examination, which was inadequate as it did not address the issue of alcohol withdrawal being a contributing factor in the death (R25). Documents were not provided to parties to the inquest (R24, 25).

Additional Royal Commission Recommendations Breached

R20 ALS to be notified immediately of all Aboriginal deaths in custody within locality.

R24 Family and ALS to be advised of progress of the Investigation/Inquest.

R25 Rights of family - view scene of death, have an independent observer present at the post mortem.

R26 Lawyer to assist Coroner to be appointed within forty-eight hours of advice of a death in custody.

R28 Lawyer assisting to be responsible for ensuring inquiry is full and adequate.

R83 Governments review all laws operating within their jurisdiction designed to deal with the public consumption of alcohol.

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

R85 Police monitoring to ensure that intoxicated persons are not held on substitute charges.

R87b Police administrators should train and instruct police in the principle that arrest be a last resort.

R88 Police should review operations where there is over-policing or inappropriate policing.

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

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

R126 Careful completion of screen form and risk assessment by a trained person to proceed placement in a cell.

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

R127c AHS involvement with Aboriginal detainees (and the necessary funding arrangements).

R127e Liaison between police and AHS to ensure transfer of information.

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

R127f(ii) Rules for care and management of Aboriginal prisoners at risk from illnesses such as epilepsy, diabetes or heart disease.

R127f(viii) Rules for care and management for Aboriginal prisoners in possession of, or requiring access to, medication.

R131 Police recording of information affecting risk.

R132 Information exchange at change of shifts.

R133 Training of police officers to recognise those in distress or at risk; advice and assistance from Aboriginal health and legal services with training.

R137 More frequent checks for prisoners at risk.

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

R145 Community-based Aboriginal cell visitor schemes in police watch-houses.

R148 Improvement of police cells, although not as priority over implementation of other recommendations.

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.

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

R214 Support for community policing with involvement of Aboriginal communities and organisations in developing procedures in areas of significant Aboriginal population.

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

R220 Funding for Aboriginal organisation providing support for community policing and community justice programs.

R221 Remuneration of community policing and community justice programme participants from expenditure on justice matters, not Aboriginal Affairs.

R223 Police, ALS and other relevant organisations consider local agreed rules on contact between police and Aboriginal people, including notification of arrest or detention, protective custody for intoxication, local concerns and community participation in decisions on police officer placement and conduct.

R332 Standard minimum guidelines for police custodial facilities throughout Australia.

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85WA

Male 45, 29 October 1995
Broome Regional Prison, Broome
Heart Attack

Coronial Inquiry Coroner Roberts

Inquest incomplete. Inquest commenced 17 June 1996.

Social Justice Commissioner

Cause of death

The post mortem report lists the cause of death as acute myocardial infarction due to coronary arteriosclerosis.

Circumstances of Death

The deceased was sentenced at the Kununurra Court of Petty Session of February 2, 1995 on two counts of breach of probation on burglary charges and one count of burglary. He was sentenced to 30 months imprisonment.

The deceased had a heart condition. On Monday 25 September 1995, five weeks prior to his death, he suffered a heart attack at the Prison. The deceased was taken to Broome District Hospital where he was examined and treated, and was kept for observation and assessment until Tuesday, 3 October 1995.

The deceased shared a cell with five other prisoners. They had been secured in their cells at 10:00pm on Sunday 29 October. Approximately 40 minutes later the deceased collapsed in the toilet within the cell. The other prisoners in the cell called the yard officer for assistance and attempted to unlock the toilet door. The rotating lock was operated on the inside by a rotating toggle, and from the outside there was only a groove requiring a screwdriver. The officer went to get a screwdriver. Meanwhile the prisoners opened the door with a folded tobacco tin.

Three prison officers attempted resuscitation. When St John Ambulance officers arrived they continued attempts at resuscitation using oxy-viva equipment and heart massage. This treatment continued in transit and at the hospital. In his statement, one of the ambulance officers noted a puncture mark on the deceased. The deceased was pronounced dead at around midnight.

Issues

The deceased was not given his medication on the afternoon/evening prior to his death and yet the medication chart was initialled by a prison officer to the effect that it had been dispensed. The evidence suggests that the initialling of the chart, which occurred on the day after the death, was arranged by the nurse.

A number of issues arose at the inquest. There were no arrangements for sophisticated testing of prisoners in Broome for heart disease, especially in relation to prisoners who exhibited symptoms of heart disease. There were no alarms in the cells. A prisoner made a statement that diet and opportunities for exercise were poor.

There were problems having the death fully investigated. The family were not notified of the death within 24 hours (R19).The Aboriginal Legal Service were not formally notified and only heard about the death when interviewing another prisoner at Broome Regional Prison (R20). Counsel Assisting was not appointed within 48 hours (R26), and according to the Aboriginal Legal Service is usually appointed very late in Western Australia. Counsel had not received any documents nine days before the inquest was set to commence (R27). The police investigation was not conducted at superintendent level (R34). Requests that a cardiologist be called to give evidence were refused until evidence came to light that the deceased may not have received his medication on the afternoon/evening of his death (R152g(viii)).

The police investigation did not address the relevant Royal Commission recommendations. Coronial recommendations for the prevention of further deaths (R13) could not have been made on the police investigation because it did not include evidence of the quality of care and treatment of the deceased prior to death (R35b, R36).

It is expected that evidence at the inquest will examine whether custodial health and safety recommendations were properly complied with (R124, R150, R154-60).

Royal Commission Recommendations Breached

R19 Immediate personal and sensitive notification by custodial institution to the family of any person dying in custody.

R20 ALS to be notified immediately of all Aboriginal deaths in custody within locality.

R24 Family and ALS to be advised of progress of the Investigation/Inquest.

R25 Rights of family - view scene of death, have an independent observer present at the post mortem.

R26 Lawyer to assist Coroner to be appointed within forty-eight hours of advice of a death in custody.

R28 Lawyer assisting to be responsible for ensuring inquiry is full and adequate.

R34 Police investigations be conducted by officers who are highly qualified as investigators.

R35 Police investigations should be approached on the basis that the death may be a homicide and inquire into treatment and supervision of the deceased.

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

R140 Installation of alarms or intercom in all cells.

R152g(viii) Protocols for care and management of Aboriginal prisoners who are in need of medication.

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86WA

Male 17, died on 29 October 1995
Thornlie, Perth, WA
Injuries in Car Accident, Police Pursuit

Coronial Inquiry Not complete.

Social Justice Commissioner

Comment

The deceased was the driver of a car which crashed while being pursued by police. He died from injuries sustained in the crash.

No other information is available at this time.

The risks and danger of high speed car pursuits involving young people is well documented. High speed car chases should be banned where children or young people are drivers or passengers of the vehicle.

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89WA

Male 17, died on 9 December 1995
Halls Creek, WA
Injuries in Car Accident, Police Pursuit

Coronial Inquiry Not commenced.

Social Justice Commissioner

Comment

The deceased was the driver of a car which crashed while being pursued by police. He died from injuries sustained in the crash. No other information is available at this time.

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95WA

Male 22, died on 24 April 1996
Canningvale Remand Centre, WA
Self-inflicted, Hanging

Coronial Inquiry Inquest not commenced

Social Justice Commissioner

Comment

The media release from the Deaths in Custody Watch Committee (WA) Inc called attention to the fact that this is the seventh death by hanging in eighteen months in Western Australia and that the young man had been held on relatively minor charges.

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ENDNOTES

1
Commissioner Muirhead RCIADIC Interim Report at 58

2
Winterton, H West Australian 20 February 1991 at 5

3 op cit

4
Commissioner D J O'Dea, Report of the Inquiry into the Death of Edward Cameron 1990.

5
From the Report on the Inquest by Counsel for the next of kin, prepared for the ALS (WA).

6 From Submission to the Inquest by ALS (WA) on behalf of next-of-kin.

7
Commissioner Patrick Dodson Regional Report into Underlying Issues in Western Australia RCIADIC p86-244, 731-760.

8
From Submission by ALS (WA) see note 1

9
RCIADIC, Report of Inquiry into the death of Misel Waigana pp12-17, 28-35, 40-50.

10 Sunday Times 10 March 1996 at 3.

11
From Submission by ALS (WA) see note 1

12 R v Taktak [1988] 14 NSWLR 226.

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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