Skip to main content

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



Western Australia

South Australia


Northern Territory

Other Deaths in Custody


Northern Territory

12NT 12/3/90 14


JDC Papunya Road, ex JDC Injury
18NT 28/4/90 48


Police Elcho Island Gunshot
50NT 30/8/93 40


Police Police Van, Darwin Natural
61NT 30/5/94 52


Prison Berrimah Prison Natural
70NT 11/2/95 21


Prison Alice Springs Prison Natural
93NT 22/2/96 35


Prison Darwin Prison Natural
96NT 1/5/96 42


Police Tiwi Island Police Station Self-inflicted



Male 14, died on 12 March 1990

Papunya Rd, ex Juvenile Detention Centre, NT

Head Injury, Car Crash

Coronial Inquiry Barritt, Stipendiary Magistrate

Finding handed down on 15 October 1990


The deceased died by misadventure.

Summing Up

Circumstances of death

The deceased and another were remanded at Giles House on charges of breaking and entering offences at Papunya. They escaped from the institution and stole a vehicle. They were joined by other youths at Charles Creek Camp. One of these youths took over the driving. He lost control of the vehicle 63 kilometres east of Papunya when trying to run over a rabbit. The deceased, who was not wearing a seatbelt, was thrown through the rear window and sustained head and other injuries.


The Coroner accepted the evidence as presented by the investigating constable (see comment below).

Recommendations Nil.

Royal Commission Recommendations Breached

Nil on the basis of insufficient information.

Social Justice Commissioner


This case was not classified as a death in custody by the Coroner's Office. Therefore, a full inquest did not occur and only a Constable presented evidence. However, a full coronial file was presented to the Coroner. This included photos, statements by the other passengers, a record of interview with the driver, post-mortem and forensic reports and a notification of death form. Nevertheless, the deceased was in custody at the time of his death (Recommendation 6d - he was the subject of a current warrant of commitment) and a full hearing should have been conducted.

Additional Royal Commission Recommendations Breached

R11 Legal requirement for public coronial inquiry into all deaths in custody. [IR45]

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

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

back to top


Male 48, died on 28 April 1990

Elcho Island, NT

Injury, Police Shooting

Coronial Inquiry Coroner Alasdair McGregor

Finding handed down on 3 June 1991


The deceased died of the effects of a shot-gun wound to the head on a beach near Galiwin'ku on Elcho Island. The shot was fired by a Senior Constable of the Task Force within the Northern Territory Police Force.

The Coroner found the evidence insufficient to put any person upon his trial for any indictable offence.

Summing Up

Circumstances of death

The deceased suffered from schizophrenia. When the illness came upon him he would often leave the Yolngu community on Elcho Island and live by himself. He was sometimes brought to the Gove or Darwin for treatment. On one of these occasions he was captured by his nephew and uncle.

On 5 February 1990 a house burnt down. Everyone believed the deceased was responsible. The deceased then threw a spear at a member of the community on 26 April 1990 which resulted in a pierced lung.

The Constable on Elcho Island called in two other police officers from Nhulunbuy. Together with the Yolngu Police Aides they began a search for the deceased. They saw the deceased among rocks below a cliff and a volunteer shone a torch into his eyes. The deceased threw a spear at him which struck the volunteer's hand. Later that night the deceased was seen with a painted body, a rope around his waist and a knife. However, the knife was reported as a machete to the police.

On 27 April five members of the Police Task Force flew to the island. The deceased was found to be at Dhayiri, a few kilometres by boat. Two relatives went out to meet him while the Task Force, Police and Police Aides came up behind the deceased.

The deceased talked with his two relatives but realised there were people behind him. He then ran to get his spears, which were now behind the position of the police. The Task Force Sergeant stood up and shouted at the deceased to stop. The Sergeant fired three shots in the air. The deceased zig-zagged and starting running towards the Senior Constable. The deceased then pulled a knife from his trousers. The Senior Constable yelled at the deceased to drop the knife. The Constable then lowered his shotgun and shot the deceased. The deceased was about 7 metres from the Constable. The deceased died an hour later.


The Coroner found that evidence from the police and Yolngu people was generally consistent. However, their perspectives differed as to the appropriateness of certain actions. The Yolngu generally felt that the deceased should have been left to himself until his sickness left him. The police, however, believed they were under the responsibility to protect the community who had been seriously affected twice by the deceased.

The Coroner held that apprehension of the deceased was necessary. However, he was critical of the police approach to the matter. He found that the Task Force should have consulted closely with the Community Council and that the deceased's uncle, a Police Aide, should not have been kept at the back of the group but allowed to call out to the deceased to stop. This omission was further compounded by the use of English and warning shots which the deceased would probably not have understood. He also criticised the police for not allowing the uncle near the deceased's body in accordance with Yolngu custom. The Coroner declined, however, to criticise the delay in the arrival of medical services, given the remoteness of the location.

The Coroner held that there was insufficient evidence to put the Senior Constable or any other person on trial for an indictable offence. He found that the evidence indicated the Constable was acting in self-defence, particularly due to the knowledge of the deceased's accuracy with spears and the report of the knife as a machete.


The Coroner did not make any formal recommendations but made a number of suggestions of how to prevent such a death in the future. These included:

(i) more concentrated mental health services;

(ii) greater co-operation of police with the Yolngu, when they are called to Elcho Island;

(iii) that Police Aides have respect for both Yolngu and Police as well as sufficient status to deal more or less equally with senior men on each side of the alliance;

(iv) if police require assistance from the Yolngu, it should be volunteered but with proper safeguards;

(v) that requirements contained in Police General Order P8 on the 'Employment of Police Trackers' be relaxed to allow better protection of Police Trackers;

(vi) s3 of the Work Health Act be amended to cover volunteers;

(vii) s28 of the Criminal Code be amended so that policemen who protect one another are not liable to prosecution when reasonable force is used;

(viii) amend s13 of the Mental Health Act (NT) to allow magistrates to commit patients to detention if they are likely to harm others or themselves without the additional requirement that the patient cannot care for themselves.

Royal Commission Recommendations Breached

IR 32 Police who interact with Aboriginal people be trained in culture and background in order that communication is possible.

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

R228 Interaction between police and Aboriginal people to be a large part of police training - to include Aboriginal disadvantage, social and historical aspects and the history of Aboriginal/police relations.

Social Justice Commissioner


The Coroner showed a large degree of sensitivity towards Yolngu customs despite rejecting a number of their submissions.

back to top


Female 40, died on 30 August 1993

Police Vehicle, Darwin, NT

Natural Causes, Respiratory Failure

Coronial Inquiry Coroner J Lowndes

Inquest not completed

Social Justice Commissioner


The inquest has been delayed due to difficulties in locating the deceased's family. The Coroner's counsel submitted his view of the facts before the case was adjourned. The following is a summary of his account. The deceased was lying on the footpath in Shepherd St, Darwin, on the morning of Monday 30 August 1993. Office workers attempted to wake her and failing to do so contacted the Police. The Police arrived, woke the deceased and helped her into the van. They took to her to the Sobering-up Shelter. She was being taken from the van when a constable asked the nursing staff to take a pulse. There was no pulse and resuscitation was unsuccessfully attempted.

back to top


Male 52, died on 30 May 1994

Berrimah Prison, NT

Natural, Heart Disease

Coronial Inquiry Coroner John Lowndes

Inquest part heard

Social Justice Commissioner


The Coroner heard evidence on 17 March 1995 and adjourned to give reasons in due course. The evidence was straightforward and was not contested by any of the parties including the representatives of the family.

The deceased was sentenced to five years imprisonment for a homicide offence. He was an inmate at Berrimah Prison and had been in custody since 9 July 1993. The deceased had a history of coronary heart disease, which was first diagnosed in September 1993. Eight weeks later he was transferred to Gunn Point Prison Farm. Three days later he was returned to Berrimah Prison after falling out of bed and suffering a fit.

He was then started on medication and routinely checked. He remained well until his death except for a complaint of chest pain in March 1994 following a fall on his shoulder. At 1:10pm, 30 May 1994 fellow prisoners notified prison officers that the deceased was having a turn. They arrived within two minutes and commenced CPR. Doctor K gave the cause of death as coronary heart disease.

This findings indicate that relevant health recommendations were followed.

back to top


Male 22, died on 11 February 1995

Alice Springs Prison, NT

Natural, Heart Disease

Coronial Inquiry Inquest not commenced

Social Justice Commissioner


The Secretary of the Correctional Services Department stated that preliminary investigations suggested the deceased had died of a brain seizure. 1 He said the man was seen having a fit in his cell about 10:00am and warders tried to revive him. The deceased had been sentenced to two and half years imprisonment for sexual assault.

back to top


Male 35, died on 22 February 1996

Darwin Prison, NT

Natural, Heart Attack

Coronial Inquiry Inquest not commenced.

Social Justice Commissioner


A Spokeperson from the Northern Territory Correctional Services Department stated that the deceased had been suffering from a heart condition and had a heart attack on 13 February 1996. 2

back to top


Male 42, died on 1 May 1996

Tiwi Island Police Station, NT

Self-Inflicted, Hanging

Coronial Inquiry Inquest not commenced

Social Justice Commissioner


A media release from Northern Territory Police, Fire and Emergency Services provided basic details of the death. The deceased was apprehended by community wardens at Nguiu, Tiwi Island after a domestic dispute. He was taken to the home of one of Nguiu's two Aboriginal Community Police Officers. They requested the deceased be locked in cells. After he was lodged in the cells, the Community Police Officer and wardens were called to a disturbance at the Health Clinic where a man had been stabbed in the neck with a sharp stick and required medical attention.

The Community Police Officer and wardens returned to the cells at about 11.15pm with a second person. They found the deceased hanging in the cells. A doctor was called but was unable to revive the deceased.

back to top


'Prisoner dies' Northern Territory News, February 12, 199, p.2.

2 "Heart Attack" Illawarra Mercury (24/2/96) p.19.




report cover

A Report prepared by the

Office of the Aboriginal and Torres Strait Islander Social Justice Commissioner

for the

Aboriginal and Torres Strait Islander Commission