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Social Justice Report 2003: Appendix three: Extract from findings of Coronial inquests in petrol sniffing on the Anangu Pitjantjatjara Lands

Social Justice Report 2003

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  • Appendix three: Extract from findings of Coronial inquests in petrol sniffing on the Anangu Pitjantjatjara Lands

    This appendix contains an extract from the findings of
    Coroner Chivell in the inquests of the South Australian Coroner's Court
    into the deaths of three Anangu on the Anangu Pitjantjatjara Lands between
    1999-2001.[1] The full findings of the Coroner
    can be accessed online at the following address:http://www.courts.sa.gov.au/
    courts/coroner/findings/findings_2002/kunmanara_ken.finding.htm

    1. Executive Summary

    1. This inquest concerns the deaths of three people,
    Kunmanara Ken who died on 3 August 1999, Kunmanara Hunt who died on 27
    January 2001 and Kunmanara Thompson who died on 26 June 2001.

    2. All three deceased died as a result of inhalation
    of petrol fumes. The mechanism of death was strikingly similar in each
    case, namely that the deceased took a can containing petrol to bed with
    them, and continued to sniff until they died from respiratory depression
    with a possible additional component of asphyxia.

    3. Each person had marks on his or her face indicating
    that the head was resting on the tin, which had been shaped to fit the
    contours of the face and achieve a seal.

    4. Each of them was of mature age (27, 25, 29 years)
    and each had been sniffing petrol for more than ten years, thereby justifying
    the description 'chronic sniffers'. Each had led lives characterised by
    illness, hopelessness, violence and alienation from their families and
    community. Each had parents and family who did their best to stop them
    sniffing, and who have endured much suffering and grief as a result of
    their inability to do so, and the consequent death of a loved family member.

    5. Petrol sniffing is endemic on the Anangu Pitjantjatjara
    Lands. It has caused and continues to cause devastating harm to the community,
    including approximately 35 deaths in the last 20 years in a population
    of between 2,000 and 2,500. Serious disability, crime, cultural breakdown
    and general grief and misery are also consequences.

    6. The phenomenon is still not well-understood, and although
    considerable research has been undertaken, Governments still do not have
    a clear idea how many people are involved, and the extent to which they
    have already suffered serious harm.

    7. The extent of the problem diminished somewhat in the
    mid 1990's, and it is apparent that there was a reduction in effort towards
    tackling the problem. It has been apparent since at least 1998 that the
    problem was returning, and that the prognosis was bad, but little has
    been achieved to restore the effort to pre-1995 levels, let alone take
    it further.

    8. Clearly, socio-economic factors play a part in the
    general aetiology of petrol sniffing. Poverty, hunger, illness, low education
    levels, almost total unemployment, boredom and general feelings of hopelessness
    form the environment in which such self-destructive behaviour takes place.

    9. That such conditions should exist among a group of
    people defined by race in the 21st century in a developed nation like
    Australia is a disgrace and should shame us all.

    10. Many attempts over the years to combat petrol sniffing
    have been unsuccessful. Anangu continue to try and care for sniffers even
    when they continue to sniff, and even after they are violent and disruptive
    to their families and the community. Some Anangu are concerned that if
    they try and stop sniffers they will harm them, or that the sniffers may
    harm themselves. They look to the broader community to help them deal
    with a problem which has no precedent in traditional culture.

    11. The South Australian Government established the Anangu
    Pitjantjatjara Lands Inter-Governmental Inter-Agency Collaboration Committee
    ('APLIICC') to tackle the wider issues and the Petrol Sniffing Task Force
    ('PSTF') to specifically tackle petrol sniffing. The terms of reference
    of APLIICC were established in September 2001. It has held several meetings,
    as have its sub-committees, but the 'big meeting' with Anangu on the Anangu
    Pitjantjatjara Lands is yet to occur.

    12. The Commonwealth Government took over responsibility
    for aboriginal health from the Aboriginal and Torres Strait Islander Commission
    ('ATSIC') in 1995. It has conducted a review and established the Central
    Australian Cross Border Reference Group on Volatile Substances Use. That
    Group has also met several times but is yet to develop a 'framework for
    action'.

    13. The establishment of these bodies met with a generally
    favourable response, although there have been criticisms about failure
    to consult, and delay. Both bodies have taken far too long to act. Their
    meetings are too far apart, and still seem stuck in the 'information gathering'
    phase. There is no need for further information gathering, and there is
    a vast untapped pool of professional expertise to be utilised. What is
    missing is prompt, forthright, properly planned, properly funded action.

    14. Many of the people in the field complained of the
    remoteness of bureaucracies, and their incessant demands for written reports
    on performance outcomes and so forth. It would be better if the bureaucracies
    appointed trusted representatives who could monitor and evaluate projects
    and programmes for themselves, rather than insisting that dedicated professionals
    in the field continue to spend valuable time and resources preparing reports
    in order to ensure continued funding. It would also be preferable, for
    a variety of reasons, if programmes are funded on a triennial basis, as
    recommended by the Royal Commission into Aboriginal Deaths in Custody.

    15. A variety of intervention strategies to combat petrol
    sniffing were analysed at this inquest. Clearly a successful strategy
    must have broad community support.

    16. Strategies at three different levels are called for:

    • Primary interventions - to reduce recruitment into substance abuse;
    • Secondary interventions - seeking to achieve abstinence and rehabilitation;
    • Tertiary intervention - providing services to the permanently disabled.

    17. Strategies include:

    • Youth activities through provision of youth workers;
    • Neuropsychological testing;
    • Outstations / Homelands;
    • Avgas;
    • Legal sanctions; Night patrols;
    • Programmes for 'Children At Risk';
    • Disability services;
    • Secure care facilities;
    • Policing;
    • Crime Prevention strategies.

    18. The implementation of any one of those strategies
    by itself is likely to fail, but introduction in combination with a variety
    of others will give a better chance of success.

    19. All these strategies must be accompanied by strategies
    to address socio-economic issues such as poverty, hunger, health, education
    and employment.

    20. The implementation of these strategies will doubtless
    involve difficult problems such as recruitment and retention of suitable
    staff. Creative solutions will need to be found. Anangu cannot be expected
    to find all of the human and other resources to tackle these problems.
    They need the assistance and input of non-Anangu professional people to
    tackle these problems directly, and to give them the power and skills
    to take up the task in due course.

    21. Anangu who gave evidence at the inquest were not
    consistent in their views about the role they felt police should take,
    although I detected a general feeling that they wanted more protection
    and security from the South Australia Police Department ('SAPOL'), particularly
    during the acute phase of incidents involving petrol sniffers.

    22. The evidence of non-Anangu witnesses was unanimous
    that a much greater, permanent SAPOL presence on the Anangu Pitjantjatjara
    Lands is called for. This was accepted in principle by SAPOL following
    a review in 1998, although the recommendations of the review have still
    not been implemented.

    23. The Community Constable Scheme is a worthwhile initiative,
    and could be improved with further training of community constables. However
    the scheme has significant limitations because of cultural constraints,
    and the fact that the Community Constables are members of very small communities.
    Their strengths lie in diffusing acute situations, and acting as liaison
    and intelligence officers.

    24. Ongoing training, support and supervision of community
    constables by sworn police officers is needed, and this will require a
    permanent SAPOL presence on the Anangu Pitjantjatjara Lands. The decision
    to station two police officers at Umuwa on a rotation basis is supported,
    but a review to assess the adequacy of this measure is necessary in due
    course.

    25. The presence of SAPOL officers in the Anangu Pitjantjatjara
    Lands could fulfil a valuable community development role in addition to
    policing issues.

    26. The establishment of SAPOL officers at Marla is significantly
    under-strength, and more needs to be done to attract officers to the area.

    27. Police are considerably inhibited from dealing in
    a more effective way with offending in the Anangu Pitjantjatjara Lands
    at present by the lack of appropriate detention facilities, lack of personnel,
    the distances involved, and the lack of sentencing options available to
    the courts.

    28. Operation Pitulu Wantima conducted in January and
    February 2000 demonstrated that police can be effective in interdiction
    and suppression of petrol sniffing, and of crime generally, if they have
    a more sustained presence on the Anangu Pitjantjatjara Lands ...

    12. Royal Commission into Aboriginal Deaths in Custody
    (RCIADIC)

    12.1 A comparison of the issues which have arisen at
    this inquest with the findings of the RCIADIC published in 1991 reveals
    that the recommendations of that inquiry have still not been fully implemented.
    An exhaustive analysis of those recommendations (339 in all) is beyond
    my capacity in the context of this inquest, but an examination of some
    specific recommendations is instructive:

    • Recommendation 88: That Police Services in their
      ongoing review of the allocation of resources should closely examine,
      in collaboration with Aboriginal organizations, whether there is a sufficient
      emphasis on community policing. In the course of the review, they should,
      in negotiation with appropriate Aboriginal organizations and people,
      consider whether:

      • a) There is over-policing or inappropriate policing of Aboriginal
        people in any city or regional centre or country town;
      • b) The policing provided to more remote communities is adequate
        and appropriate to meet the needs of those communities and, in particular,
        to meet the needs of women in those communities; and
      • c) There is sufficient emphasis on crime prevention and liaison
        work and training directed to such work. (Page 51).
    • Recommendation 113: That where non-custodial sentencing
      orders provide for a community work or development program as a condition
      of the order the authorities responsible for the program should ensure
      that the local Aboriginal community participates, if its members so
      choose, in the planning and implementation of the program. Further,
      that Aboriginal community organizations be encouraged to become participating
      agencies in such programs (Page 55).
    • Recommendation 195: That, subject to appropriate
      provision to ensure accountability to government for funds received,
      payments by government to Aboriginal organizations and communities be
      made on the basis of triennial rather than annual or quarterly funding
      (Page 74).
    • Recommendation 238: That once programs and strategies
      for youth have been devised and agreed, after negotiation between government
      and appropriate Aboriginal organizations and communities, governments
      should provide resources for the employment and training of appropriate
      persons to ensure that the programs and strategies are successfully
      implemented at a local level. In making appointment of trainers preferences
      should be given to Aboriginal people with a proven record of being able
      to relate to, and influence, young people even though such candidates
      may not have academic qualifications (Page 84).
    • Recommendation 265: That as an immediate step towards
      overcoming the poorly developed level of mental health services for
      Aboriginal people priority should be given to complementing the training
      of psychiatrists and other non-Aboriginal mental health professionals
      with the development of a cadre of Aboriginal health workers with appropriate
      mental health training, as well as their general health worker training.
      The integration of the two groups, both in their training and in mental
      health service delivery, should receive close attention. In addition,
      resources should be allocated for the training and employment of Aboriginal
      mental health workers by Aboriginal health services (Page 91).
    • Recommendation 286: That the Commonwealth Government,
      in conjunction with the States and Territories Governments and non-government
      agencies, act to co-ordinate more effectively the policies, resources
      and programs in the area of petrol sniffing (Page 94).

    12.2 It can be seen that simply by analysing the facts and circumstances
    of these three deaths, and the circumstances which still exist on the
    Anangu Pitjantjatjara Lands at the moment, those recommendations of the
    RCIADIC have not been complied with, either by Commonwealth or State Governments.

    12.3 This is a great tragedy which I have no doubt will, if it is not
    addressed, lead to severe disability and further deaths, not to mention
    continuing social dislocation, crime, loss of culture and general community
    degradation and loss.

    13. Recommendations

    13.1 I am empowered by section 25(2) of the Coroners Act, 1975, to make
    recommendations following an inquest if, in my opinion, to do so may 'prevent,
    or reduce the likelihood of, a recurrence of an event similar to the event
    that was the subject of the inquest'.

    13.2 Having considered the
    evidence in this matter and the detailed and very helpful submission of
    counsel, I consider that it is appropriate to make the following recommendations:

    1. That Commonwealth, State and Territory Governments recognise that petrol sniffing poses an urgent threat to the very substance of the Anangu communities on the Anangu Pitjantjatjara Lands. It threatens not only death and serious and permanent disability, but also the peace, order and security of communities, cultural and family structures, education, health and community development.

    2. Socio-economic factors such as poverty, hunger, illness, lack of education, unemployment, boredom, and general feelings of hopelessness must be addressed, as they provide the environment in which substance abuse will be resorted to, and any rehabilitation measures will be ineffective if the person returns to live in such conditions after treatment.

    3. The fact that the wider Australian community has a responsibility to assist Anangu to address the problem of petrol sniffing, which has no precedent in traditional culture, is clear. Governments should not approach the task on the basis that the solutions must come from Anangu communities alone.

    4. The Commonwealth Government, though the Central Australian Cross Border Reference Group, and the South Australian Government through the Anangu Pitjantjatjara Lands Inter-Governmental Inter-Agency Collaboration Committee, should accelerate their efforts to find solutions to these issues and get beyond the 'information gathering' phase forthwith. They should use the extensive knowledge, published material and professional expertise that is already available.

    5. It is particularly important that Inter-Governmental coordination of approach be a high priority in order to avoid the fragmentation of effort and confusion and alienation of service-providers which are features of current service delivery to Anangu communities.

    6. Commonwealth and State Governments should establish a presence in the region, if not on the Anangu Pitjantjatjara Lands then at least in Alice Springs, of senior, trusted officials, in order to develop local knowledge, personal relationships with service providers and receivers, and some expertise and experience in cross-cultural issues, rather than relying on infrequent meetings with ever-changing officials in order to communicate with Anangu. Such officials should be invested with sufficient authority to manage and assess programmes on an ongoing basis, so that service providers can have a line of communication with the funding body, and some certainty as to future arrangements.

    7. Many of the strategies for combating petrol sniffing which have been tried in the past should not be discarded simply because they failed to achieve permanent improvements. Some of them might be regarded as having been successful for as long as they were extant. For any strategy to be successful will require broad Anangu support. Most strategies will fail unless they are supported by others as part of a multi-faceted approach. Strategies should be aimed at primary, secondary and tertiary levels, as I have outlined in these findings.

    8. In particular:

    8. 1 The proposal before the Tier 1 Committee of APLIICC to appoint four youth workers and a coordinator for the Anangu Pitjantjatjara Lands should be implemented forthwith. Practical issues such as employment conditions, housing conditions and the like must be dealt with. The situation should be monitored to ensure that this number is sufficient to meet the needs of all communities;

    8. 2 A programme of further research and evaluation of people who have been sniffing petrol, on a neurological and neuropsychological basis, should be instituted so that assessments can be made about the suitability of candidates for rehabilitation, and the level of need for disability services on the Anangu Pitjantjatjara Lands can be evaluated;

    8. 3 The establishment of a culturally appropriate Homelands/Outstation programme should be undertaken to provide a venue for community respite, recreation, skills training, education and the like in the context of abstinence from petrol sniffing. Such establishments should not be considered as rehabilitation facilities for chronic petrol sniffers;

    8. 4 The Commonwealth Government should continue to resource the Avgas initiative through the Comgas scheme, as it represents a successful interdiction strategy without which petrol would be much more widely available;

    8. 5 The range of sentencing options available to courts sitting in the Anangu Pitjantjatjara Lands must be increased. The SA Department for Correctional Services must provide supervisors so that bonds, undertakings and community service obligations can be enforced. The establishment of Outstations/Homelands, and a secure care facility would also provide options to courts;

    8. 6 The Public Intoxication Act should be amended so that it applies on the Anangu Pitjantjatjara Lands. There should be a declaration that petrol or hydrocarbons, or the vapours thereof, are a drug for the purposes of the Act. A secure care facility would provide a 'sobering up' facility to which detainees could be taken pursuant to the Act;

    8. 7 Although night patrols have not received support on the Anangu Pitjantjatjara Lands to date, the possibility of encouraging and supporting Anangu to establish them as part of an overall crime prevention strategy in consultation with SAPOL should be explored;

    8. 8 APLIICC should consider the future role of FAYS in relation to children at risk on the Anangu Pitjantjatjara Lands, and in particular whether their role needs to be expanded into a much more proactive community development role;

    8. 9 The level of services for disabled victims of petrol sniffing should be urgently upgraded. The recommendations of Mr Tregenza's review should receive urgent consideration (it has been in the hands of the SA Government for six months or more) and implemented where practicable;

    8. 10 Planning for the establishment of secure care facilities on the Anangu Pitjantjatjara Lands should commence immediately. These facilities must be reasonably accessible from all communities on the Anangu Pitjantjatjara Lands, and have a multi-functional role to provide facilities for detention, detoxification, treatment and rehabilitation as outlined in these findings;

    8. 11 A much more energetic, concerted and creative approach to recruitment of suitably qualified experienced and appropriate staff will need to be undertaken in order to attract people to employment in the implementation of these strategies;

    8. 12 The implementation of the recommendations of the SAPOL review into the Community Constable Scheme, in particular concerning establishment of a permanent, sworn SAPOL presence on the Anangu Pitjantjatjara Lands, should be undertaken forthwith. The proposal to station two officers at Umuwa is a start, but the abandonment of the proposal to establish another base in the Western area, at Murpatja, should be reconsidered in order to provide an appropriate degree of training, support, and supervision of Community Constables;

    8. 13 Further measures need to be taken by SAPOL to ensure that the staff establishment at Marla is at full strength. Although efforts made to address this issue to date are recognised, the station remains under-strength, and is unable to provide an effective policing service on the Anangu Pitjantjatjara Lands, at present, resulting in under-reporting of crime and a general disenchantment with the level of police service among Anangu;

    8. 14 The interventions described above must be implemented as part of an overall multi-faceted strategy, and not piecemeal, as they are interdependent and stand a high chance of failure if they are introduced separately;

    8. 15 The recommendations of the Royal Commission into Aboriginal Deaths in Custody should be re-examined by both Commonwealth and State Governments as a check to assess the degree to which those recommendations have still not been implemented.


    1. Chivell, W, Findings of the South
    Australian State Coronial Inquest into the Deaths of Kunmanara Ken, Kunmanara
    Hunt and Kunmanara Thompson,
    6 September 2002.