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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



Western Australia

South Australia


Northern Territory

Other Deaths in Custody


Other Deaths in Custody

A1SA 13/2/91 43


SUS Royal Adelaide Hospital Head Injuries
A2SA 1/3/91 35


Prison RAH ex Port Augusta Prison Natural
A3NSW 20/7/92 25


Police Kempsey Police Station Self-inflicted
A4WA 9/7/94 18


Police Perth Car crash
A5WA 22/7/94 16


Police Perth Car Crash
A6NSW 17/11/95 18


Hospital Blacktown Hospital Drugs
A7QLD 12/1/96 21


Hospital John Oxley Memorial Hospital Self-inflicted



One of the deaths in this section has now been acknowledged by the South Australian Government in its 1994/95 implementation report as a death in custody (A2SA). The prisoner in the case was 'released' from custody on his deathbed.

A number of cases fell outside the narrow interpretation of recommendation 6, discussed in chapters 1 and 10. While recommendation 6 states that deaths in custody 'should include at least' the categories (a) to (d) deaths outside the categories have not been classified as deaths in custody. Therefore many deaths which involve custodial authorities are not the subject of coronial investigation.

A number of cases demonstrating this problem are included in this appendix:

  • an unconscious person who died after being taken to a sobering-up shelter by police in the mistaken belief that the person was merely intoxicated (A1SA) ;
  • two youths who died in car chases after police (a) ceased active pursuit, or (b) were allegedly pursuing in relation to another matter but became somehow involved in the circumstances of the death (A4WA, A5WA);
  • a death which occurred after contact with police and court system (A6NSW); and
  • a person incarcerated in a mental institution for a criminal offence and held under the Mental Health Act after his sentence expired (A7QLD).

These deaths require full post-death investigation 1. Whether such deaths should be classified as deaths in custody is a moot point. The Royal Commission stated that:

[T]he essential quality which attracts the public interest� is the exercise of power conferred on officers entrusted with a public duty� to ensure that they have been exercised in a reasonable justifiable way and have not been abused. When considered in this perspective, coronial jurisdiction to inquire into the circumstances should not be confined to situations where the deceased has actually been taken into custody. 2

Indeed in one of these cases (A7QLD) the inquiry recommended that:

[T]he definition used by the Royal Commission of an Aboriginal death in custody be extended to cover deaths which occur while a patient is in custody in a Queensland Health facility.

The appendix also includes the death of a man at Kempsey Police Station (A3NSW). The Coroner found that the deceased was not Aboriginal but Redfern Aboriginal Legal Service have stated that the deceased was adopted by a non-Aboriginal family.

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Male 43, died on the 13 February 1991

Royal Adelaide Hospital, SA

Head Injuries

Coronial Inquiry Coroner Kevin Ahern

Finding handed down on 26 July 1991


The cause of death was due to skull fracture, which in turn resulted in intra cerebral and subarachnoid haemorrhages, as noted at post-mortem.

Summing Up

Circumstances of death

The deceased had been drinking with a group of Aboriginal people on 12 February 1991. They were seen outside the Woolworths store, in Tassie Street, Port Augusta, about 7.30-7.45pm. The deceased was observed to be lying near a wall of the Woolworths building. Shortly after, the group of people left in a taxi.

The deceased was observed at 9.10pm by a police constable in a car. He formed the opinion that the deceased was under the influence of alcohol. Due to communication breakdowns the deceased was not picked up by police until 10.10pm. Police shone a light into the deceased's eyes but his eyes were unresponsive to the light. However, the constable did not pay attention to this phenomenon.

The deceased was taken to a sobering-up centre at Port Augusta. A nurse saw the deceased in the morning. He unsuccessfully attempted to raise the deceased. He then applied painful stimuli as well as putting pressure on the deceased's earlobes. There was no response. The nurse had an ambulance called and the deceased was taken to the casualty section of Port Augusta Hospital and a few hours later to the Royal Adelaide Hospital by air ambulance. He died late that afternoon from a skull fracture.


The Coroner referred to the submissions of the Aboriginal Legal Rights Movement where he stated:

[The solicitor] points out, quite properly that the particular sobering-up centre, and any other such centre, should be aware that they have a duty of care to clients. In particular she points out, that the sobering-up centre particularly areas where there are likely to be Aboriginal clients, should be aware of the health issues involved.

The Coroner agreed with the submission of counsel assisting him that sobering-up centres should follow the same procedures and safeguards as those recommended in relation to prisons by the Royal Commission.

The Coroner held that the diagnosis by police was reasonable in the circumstances. He referred to comments made by the Royal Commission that police officers cannot, and should not, be expected to make a diagnosis of a prisoner's medical condition. 3

The Coroner found that both the police officers and care workers appeared to be committed and caring professionals, performing a difficult job.


The Coroner recommended that:

1. In any case of gross impairment or apparent unco-ordination or incoherence of speech of the detainee, he or she be accorded immediate medical treatment.

2. It is highly desirable that personnel in sobering-up centres should be ever alert to the possibility that one of their clients might be suffering from some condition other than alcoholism.

3. In the case of mental trauma, of course, a fairly basic test is that of testing the subject to see whether he or she responds to painful stimuli or perhaps to light. The lack of response is evidence by the reaction or not of the eyes to light. This I believe is a test which would not be too difficult to conduct which would then alert the personnel to the likelihood that the person concerned may be suffering from some other condition, apart from that of over-indulgence in alcohol.

4. That even if there is the slightest doubt in any given case, that such person should be accorded immediate medical treatment.

Royal Commission Recommendations Breached

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

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

Social Justice Commissioner


While the Royal Commission stated that police cannot take the place of nurses they emphasised that officers need to make a preliminary assessment of detainees, observe closely any changes and not make assumptions about the possible cause of certain unusual or unexplainable behaviour (for example, intoxication). 4

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Male, 35, died 1 March 1991

Royal Adelaide Hospital ex Port Augusta Prison

Acute Bilateral Bronchopneumonia

Coronial Inquiry Coroner Alasdair McGregor

Finding handed down on 3 June 1991


The deceased died from acute bilateral bronchopneumonia, having been transferred from Port Augusta Prison to the Royal Adelaide Hospital.

Summing Up

Circumstances of death

The deceased was a Pitjatjantjara man who spoke very limited English. He had a history of petrol sniffing. He began a prison sentence for an unspecified (but apparently minor) offence on 15 January 1991. According to witnesses, the deceased looked emaciated and under-nourished on his arrival at the prison.

The deceased complained of chest pains on 11 February. He was seen by a doctor at Port Augusta Prison, who made no diagnosis. He was readmitted on 17 February, and when seen by a doctor the following day, it was decided that he be transferred to Adelaide for specialist care.

Prior to leaving for Adelaide, nursing staff from the Port Augusta Prison were requested to attend at the front gates and assess the deceased's condition. The nursing staff felt that the deceased was not fit enough to travel, especially not in a prison vehicle. The nursing staff mentioned this to management. However, the deceased was taken to Adelaide in a prison vehicle. Staff responsible for the transfer also felt that the deceased was too sick to travel by prison vehicle. On the particular day the temperature was above 30 degrees, and the air-conditioning unit in the prison vehicle apparently broke down shortly after the three-hour trip began.

On arrival in Adelaide, the deceased was taken to the Yatala infirmary, where it was noted by staff that he was 'in a very poor condition.' Due to the concerns of medical staff at Yatala, arrangements were made to immediately transfer the deceased to Modbury Hospital. The deceased was then transferred to the Royal Adelaide Hospital, where he died a few days later.


The Coroner stated that he had no hesitation in finding that the mode of transportation was inappropriate. He implied that the conditions during transportation may have been a contributing factor in the death.

The Coroner also noted that someone from the Prison Authority decided to discharge the deceased from the prison system after it was discovered that he was seriously ill. The Coroner suspected the motives for this decision, and noted that his language problems and illness would in any case have left the deceased unaware that he had been discharged.

The Coroner accepted that employees at the Port Augusta Prison Complex did not have appropriate training concerning Aboriginal culture, as recommended by recommendation 155.


That prison officers should have at least some basic knowledge of the Pitjatjantjara language.

That the families of Aboriginal persons incarcerated in the Port Augusta Gaol or any other complex should be advised from time to time of any movement of the particular prisoner.

That prison authorities keep background information on whether prisoners have a history of petrol sniffing.

Royal Commission Recommendations Breached

R152b Review of health services provided to Aboriginal detainees with AMS and other bodies to consider standard of health services available, and particular attention to drug rehabilitation.

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

R161 Prison employees to immediately seek medical attention if any doubt arises as to a prisoner's condition.

Social Justice Commissioner


The family argued that the deceased should not have been imprisoned. The fact that the sentence was imposed by a Court of Summary Jurisdiction would indicate a relatively minor offence. The Coronor dealt with the imprisonment issue by stating that he knew little of the circumstances concerning the offences for which the deceased was sentenced to imprisonment. The fact that this evidence was not available to the Coroner indicates an incomplete post-death investigation by police (R12 and R35). The Coroner accepted the inadequate information without criticism.

The Coroner failed to make preventative recommendations about the inappropriate transportation of the deceased (R13). It was also put to the Coroner that Counsel Assisting the Coroner was only briefed at the very last minute, and had no opportunity to examine prison and hospital records (R24).

The Coroner also failed to comment on the submission that the deceased had been given penicillin, despite medical records from a previous incarceration four years ago indicating that he was allergic to penicillin (R157). It was noted by the Counsel assisting the Coroner that a full medical assessment was made several days after his admission and not within 72 hours, despite his evident poor health on reception (R156).

Additional Royal Commission Recommendations Breached

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

R13 Coroner to make recommendations to prevent further deaths.

R24 Appointment of Counsel Assisting the Coroner within 48 hours of the death.

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

R92 Imprisonment as a last resort.

R152g(vii) Protocols for care and management of prisoners with serious medical conditions.

R156 Assessment by medical practitioner within 72 hours of reception.

R157 Access to medical records from prior periods of incarceration.

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Male 25, died on 20 July 1992

Kempsey Police Station, NSW

Self-inflicted Hanging

Coronial Inquiry Deputy State Coroner Derek Hand

Finding handed down on 24 March 1993


The deceased wilfully hanged himself.


Circumstances of death

The deceased was arrested for allegedly maliciously damaging property at a hotel. A search was carried out in the back of the police truck and at the police station. The deceased kept a belt from police detection, presumably under his jeans. He was loud and abusive in the cells and apparently indicated he would hang himself. The deceased hanged himself in between police inspections.


The Coroner found that police did everything appropriate in their search of the deceased. He found that the deceased had probably kept the belt as a matter of perceived necessity as opposed to its use in a suicide attempt.

The Coroner, on inspection of the facilities, found that the police would not have heard any threats of suicide which were heard by a detainee in the adjacent cell. He found that the inspections were reasonable and adequate and complied with the Royal Commission.

The Coroner found that police had failed to fill out the Prisoner Admission Form properly. He also noted Constable Berry's statement that he had not read the Commisisoner's instructions. The Coroner also found that the cell design should be changed.

Coronial Recommendations

To the Minister of Police that the proposal to change the cell design standard, as accepted at the State Commander's Action Team meeting of 12 February 1993, be implemented as soon as practicable

Royal Commission Recommendations Breached

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

R144 Aboriginal detainees not to be left alone in police cells; place with other Aboriginal person.

R148 Cell refurbishment, replacement of dilapidated cells, but not in place of implementing the other custodial health and safety recommendations.

Social Justice Commisisoner


The Coroner held that the deceased was not Aboriginal despite submissions of counsel. According to Redfern Aboriginal Legal Service the deceased was adopted by a non-Aboriginal family. 5 NSW police deny that the deceased was Aboriginal but the deceased had previously been represented by the Aboriginal Legal Service.

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Male 18, died on 9 July 1994

Perth, WA

Injuries in car crash

Coronial Inquiry Ivan Brown SM

No Inquest Held


The deceased had a history of driving offences, and had been disqualified for life from driving when he was 15 years old. He was sighted by police while driving a stolen car.

Police radioed, stating that the deceased's car had turned up the 'off ramp' of the Roe Highway. They activated their blue lights, but stated that they did not pursue the deceased at speed. Police stated that they lost sight of the deceased's car.

An officer on a police motorcycle then saw the deceased's car travelling on the wrong side of the Roe Highway, and then on the wrong side of the Great Eastern bypass. The officer's statement indicated that he was held up by traffic lights, although he had turned his siren on. He stated that he was concerned about the adverse conditions and followed at about 80kph.

The vehicle driven by the deceased then collided with another vehicle. It was still on the wrong side of the road. The driver of the other car was not seriously injured. The police car which first sighted the deceased was travelling on the correct side of the road, and did not see the accident. The officers stated that they turned back and discovered the accident.

The deceased apparently struggled, and was taken to hospital in an ambulance with a police escort. He died in hospital from his injuries.

The Coroner and the Western Australian Attorney General refused a request from the family that an Inquest be held. The Coroner published findings based on written statements taken by investigating police. A 16 year old passenger in the car driven by the deceased alleged that there had been a police pursuit, and that police had prevented them from returning to the correct side of the road. Police maintained that they were following the car driven by the deceased without making any attempt to keep up.

With corroborating accounts from three independent witnesses contradicting the account of the surviving passenger, the deceased was found not to have been involved in a high speed chase with police. The passenger had stated that they could not cross over to the correct side of the road because the police were driving beside them at speed.

Social Justice Commissioner

The evidence that both the officers in the police car and on the motorcycle had their sirens flashing suggests a pursuit. Recommendation 6c of the Royal Commission defines a death in custody to include 'the death of a person wherever occurring who dies or is fatally injured in the process of police or prison officers attempting to detain that person'. Even if they were not in the immediate vicinity of the deceased at the time of the accident, it is difficult to understand why police had their sirens on if they were not attempting to detain the deceased. The time of arrival of police at the scene was not transcribed from the Police Communications tape. Without the evidence of witnesses being tested in an Inquest, suspicions can persist that the police evidence was inaccurate.

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.

Royal Commission Recommendations Breached

R6 Inquests should follow all deaths in custody.

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Male 16, died on 22 July 1994

Perth, WA

Injuries in car crash

Coronial Inquiry No Inquest Held

Social Justice Commissioner


The deceased had an extensive history of traffic offences. He was driving a stolen vehicle which was pursued at high speed by police. The deceased was killed in an accident. While a police pursuit vehicle was somehow involved, findings on brief inquiry indicate that the pursuit car was involved in another matter. The cousin of the deceased was in the car and survived the accident.

After the incident, a talkback radio commentator named H. Sattler engaged in a villification of the 16 year old boy's parents, claiming, without basis, that they were to blame for the incident. While the culpability of the boy in stealing the car is undisputed, the cheap sensationalisim and cruelty of attacking grieving parents so publically was a sad reflection on the commentator and his radio station.

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Female, 18, died on 17 November 1995

Blacktown Hospital, NSW

Drug Overdose

Coronial Inquiry Inquest not commenced.

Social Justice Commissioner


The deceased had a long term history of psychiatric illness. An Aboriginal Health Liaison Officer with the Central Coast Area Health Service, a Registered General Nurse, took an interest in her case and attempted on several occasions to ensure that the deceased received proper psychiatric attention.

On 19 October 1995 the Aboriginal Health Liaison Officer was paged late at night by a resident at Gosford Hospital. The doctor said he had a patient (the deceased) who needed psychiatric attention. The deceased had turned herself in for warrants relating to the breaking a shop window. She had taken an overdose in police cells, and she was in possession of a razor blade. She was hurting herself and threatening people. The Aboriginal Health Liaison Officer asked that the deceased be kept in observation. She asked the doctor in charge to admit her overnight for observation to Mandala Clinic at Gosford Hospital, a specialist psychiatric unit.

There is a suggestion that the Mandala Clinic had not in the past been of assistance in matters in which police were involved, including suggestions that they were not prepared to make findings which would allow the court to make an order for psychiatric treatment. In any case, there was an argument between the Aboriginal Health Liaison Officer and the Doctor, who refused to direct the deceased to the Mandala Clinic. The deceased was given a body search. More pills were found. She was then returned to the police cells.

At 6:45am on the 20 October the Aboriginal Health Liaison Officer visited the cells. The deceased was still very drowsy and lethargic. The Aboriginal Health Liaison Officer contacted the Aboriginal Legal Service at Newcastle. That morning the deceased went to court. The Aboriginal Health Liaison Officer talked to a Legal Aid solicitor because the Aboriginal Legal Service could not get down. The Liaison Officer asked the solicitor to request a bail condition that the deceased enter a mental health facility. The solicitor discovered when he attended court that the police had agreed to bail with conditions which were not onerous and on the instructions of the deceased accepted the conditions. The deceased was bailed to appear in court again on 2 November.

On Tuesday 14 November the Aboriginal Health Liaison Officer followed up the incident at the Mandala Clinic at Gosford Hospital by having a meeting about strategies for Aboriginal mental health care. She felt that the meeting was productive and that past problems would be rectified.

On 15 November the Aboriginal Health Liaison Officer was again paged at 12:48am by Gosford Police. The deceased was threatening to harm herself. The Aboriginal Health Liaison Officer spoke to the police about her, and contacted the Acute Mental Health Team (Mental Health Crisis Team). They contacted the police, but did not get back to her.

The Aboriginal Health Liaison Officer called police and again requested that the police send the deceased to a mental health facility, as the deceased was at risk of self-harm. Police said that the Aboriginal Health Liaison Officer would have to approach the police prosecutor, and she did so. She explained that the deceased was suicidal, and requested as a bail condition that the deceased be given mental health supervision in the form of psychiatric treatment at James Fletcher Hospital, Newcastle. The police prosecutor said he would oppose even conditional bail.

The Aboriginal Health Liaison Officer then requested, if the prosecutor was determined to oppose bail, that he request a condition that the deceased be sent to the rehabilitation/mental health unit at Long Bay Gaol in Sydney. She then telephoned the Legal Aid Commission to ask the solicitor for the deceased to request the same bail condition or a court order for psychiatric care, but could only leave a message. The solicitor did not get the message until after court finished.

The Legal Aid Solicitor later called the Aboriginal Health Liaison Officer and told her that the magistrate had released the deceased on bail on condition that she attend Moree police station three times a day. Apparently the deceased had a boyfriend in Moree. The solicitor later heard that the deceased was headed to Sydney in breach of her bail.

The deceased came to Sydney instead of going to Moree. She overdosed. She died in Blacktown Hospital after being brain dead for a period of one or two days.


The Aboriginal Health Liaison Officer was concerned that the police prosecutor, when he was opposing or negotiating the bail conditions, did not mention to the magistrate or the opposing solicitor that she had contacted him and asked to request mental health assessment.

Under the Mental Health (Criminal Procedure) Act 1990 (NSW) section 33, the court can direct psychiatric assessment at the request of either side if there is evidence of some sort of psychiatric condition. Mandala is apparently the only facility available near Gosford. The person is compulsorily admitted by order of the court, usually by police. Two Psychiatrists must report and determine whether there is a mental illness as defined in chapter 3 of the Mental Health Act. Section 32 covers the situation where an accused suffers a psychiatric episode at the time of an offence, rather than at the time of appearance before the court. The section allows the court to make orders as to psychiatric care.

The police prosecutor has an ethical duty to assist the court by informing the court of any information relevant to the best interests of the deceased. It should also be noted that the duty of care owed by police can persist after a detainee is transferred from police custody. 6

Recommendation 127 calls for the involvement of Aboriginal health organisations in the medical or psychiatric care of Aboriginal people in police custody. Parts (c), (e), and (f)(i) and (iii) are directly relevant in the circumstances. A protocol which requires an Aboriginal Health Liaison Officer to be called, but then allows he or she to be ignored, is inadequate implementation of recommendation 127.

The deceased may have given instructions that she did not want to be directed for psychiatric assessment. However, a suicidally depressed client with a psychiatric problem is unlikely to be in a position to give instructions in line with her own best interests. Recommendation 127 calls for protocols to be followed where detainees are at risk of self-harm or suffering episodes of mental illness.

The case revealed a lack of liaison with the Aboriginal Health Liaison Officer, poor psychiatric assessment in police cells, lack of psychiatric facilities available in the region, and a lack of police ability to deal with psychiatric episodes generally.

In a welcome development since the death, the Central Coast Area Health Service has taken on employee to evaluate the need for a permanent Aboriginal Psychiatric nurse position.

Royal Commission Recommendations Breached

R127 c Involvement of Aboriginal health organisations in care of Aboriginal detainees.

R127 e Liaison between police and Aboriginal health organisations to ensure transfer of information.

R127 f (i) Protocols to be followed where detainees are at risk of self-harm.

R127 f(iii) Protocols to be followed where detainees are suffering episodes of mental illness.

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Male 21, died on 12 January 1996

John Oxley Memorial Hospital, Qld

Self inflicted Hanging

Inquiry Inquest not yet completed.

Circumstances of Death 7

The deceased was found dead after tying his shirt around his neck and hanging himself from a window security grille in the high security Urquhart Unit of the John Oxley Memorial Hospital (JOMH).

The deceased had suffered from a severe intractable chronic paranoid schizophrenic illness since the age of 17, a prominent feature of which was persistent auditory hallucinations directing him to commit suicide. The deceased was described as unresponsive to anti-psychotic medication, and generally reluctant to take medication prescribed to him.

The inquiry found that the deceased took the opportunity to end his life deliberately and that no blame could be attached to any individual or group for his death. 8 The hanging took place between observations by a nurse at 15 minute intervals.

The mother of the deceased was interviewed by the Inquiry, accompanied by three of her family. She stated that the deceased was almost always talking of committing suicide and that she could always talk him out of it. The other family members confirmed this. The Inquiry also noted one very significant social stressor. Less than two weeks before his arrest the uncle of the deceased killed four of his family members, and the deceased was of the impression that people thought that he had committed the killings.


The Terms of Reference of the Inquiry into the deceased's death included a review of operations at JOMH. A psychiatrist and two other health professionals undertook the Inquiry, which included calling for written submissions and conducting interviews with hospital staff, patients, Aboriginal and Torres Strait Islander agencies and other stakeholders. Police files and autopsy details were provided.

Whilst at JOMH, the deceased was secluded on four occasions for altercations with other patients. The Inquiry found that Aboriginal and Islander patients complain frequently of being secluded. It found that seclusion should be a last resort, and had dubious therapeutic value. It also found that a number of the recommendations of the Royal Commission had not been adequately implemented in the hospital and that health facilities had a significant way to go before the real and special needs of Aboriginal and Torres Strait Islander patients are fully realised and addressed.

The Inquiry found no inappropriate action by the police. It commended police following a previous incident in which the deceased had broken the window of a TAB, but was not charged because of his obvious mental condition. 9 Interviews with medical practitioners did not identify any lack of proper psychiatric care, assessment or treatment of the deceased while at the facility. However, the Inquiry concluded that although existing policies and procedures had been adhered to, the system of care experienced by the deceased was not optimal and was not in line with current understanding of best practice in forensic mental health.

The Inquiry noted that medication was prescribed very frequently following incidents. The inquiry noted that the deceased had been secluded for seven day periods on four occasions in two months, and that seclusion was tantamount to solitary confinement. There was evidence that the deceased found seclusion distressing. 10 The Inquiry also noted that one of the instances of seclusion followed an incident in which the deceased alleged that he had been sexually assaulted by another inmate. There was no evidence that the deceased was interviewed by the ward doctor or that an incident form was completed, as required under the Hospital's 'Sexual Harassment (Alleged) Policy.'

The Queensland Minister for Health at the time agreed that the requirement for all people serving sentences to be housed in the JOMH, a high security facitily, was inappropriate. Persons serving sentences for very minor offences must by law be placed with very disturbed persons convicted of serious offences. All remand prisoners are housed in the maximum security unit, which can be highly inappropriate. The Inquiry also criticised the enforced inactivity and boredom within the Urquhart Unit in which the deceased was incarcerated.

Finally, the Inquiry noted that the Queensland Mental Health Plan includes the establishment of a forensic Court Liaison Service to provide specialised assessment and referral at the time of first court appearance and the establishment of a mobile intensive treatment team to provide assessment and assertive follow-up to prevent people with mental disorders becoming inappropriately involved in the criminal justice system. It was noted that this has obvious implications for service reorganisation and for staff development. 11


The Inquiry made some forty-four recommendations. They included:

  • That the Mental Health Act be amended to allow more latitude in the admissions of mentally ill offenders so that facilities other than John Oxley Memorial Hospital can be considered in less serious situations.

  • That air conditioning be installed ugently (this recommendation was also made in a 1991 review - temperatures exceed 40 degrees in summer).

  • That the use of seclusion be reviewed and procedures put in place to become more proactive in the management of this practice; that proper statistics be kept on the use of seclusion; that the routine practice of writing seven day advance seclusion orders cease; that patients be given prior information about seclusion, and the therapeutic goals and the circumstances under which seclusion is instigated; that debriefing is offered to patients after incidents of seclusion; and that further investigation is conducted into the impact of seclusion on Aboriginal inmates.

  • The drafting of various new policies, including a policy for assessment and management of suicide risk.

  • Individual and group programs to replace enforced inactivity in the Urquhart Unit.

  • That an Aboriginal mental health worker be employed to work with Aboriginal and Torres Strait Islander patients at the JOMH. 12

  • That the definition used by the Royal Commission of an Aboriginal death in custody be extended to cover deaths which occur while a patient is in custody in a Queensland Health facility.

  • That the Aboriginal Liaison Officer currently employed by Queensland Health should be consulted and involved in the development of any policy which will have an impact on Aboriginal patients in the Wolston Park Hospital Complex.

  • Protocols to ensure better handling of agressive behaviour.

  • That staff at all levels receive training in the standards expected for patient notes and records.

  • That a standard information package should be developed for the relatives of patients.

  • That an effective complaints handling system be introduced.

  • That a 'buddy system' be introduced in cases where a patient is at risk of self-harm.

The Queensland Health Department has stated its intention to establish a steering committee to oversee the implementation of recommendations of the Inquiry, and report to the Minister regularly on the progress of implementation.

Royal Commission Recommendations Breached

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

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

R247 Training, liaison to ensure that culturally appropriate health services are provided to Aboriginal people.

R250 That appropriately screened health workers should not be denied access to reading and recording of vital information in Patients' Progress Notes.

R253 Design and operation of health facilities to consider needs of Aboriginal people particularly where their population is concentrated.

R254 Aboriginal involvement in assessing needs and delivering health services - including representation on Hospitals Boards where Aboriginal patients represent a high proportion of patients.

R256 Further employment of Aboriginal health and support staff in mainstream health facilities serving Aboriginal clients; attention to their involvement to avoid role conflict.

R287 Drug and alcohol programs for detainees.

Social Justice Commissioner


The Inquiry took submissions from Aboriginal groups, and is to be highly commended for its thoroughness. The Inquiry took a broad view of its terms of reference, and the opportunity was taken to examine various custodial psychiatric care issues including: (a) the lack of facilities in North Queensland, requiring detainees with psychiatric illnesses to be transferred thousands of kilometres; (b) the auditing of medication, complaints and observation procedures; and (c) staff mix and staffing levels, especially the use of untrained casual staff. The Inquiry noted an unrelated incident in which an Aboriginal inmate had been informed of the death of a relative, but was refused a request for a telephone call because it was against the rules to use the telephone before three o'clock. 13

The Inquiry reflected the findings of the Royal Commission in that there was evidence of a gross over-representation of Aboriginal and Torres Strait Islander people in custodial care facilities. Approximately 20 to 25% of the patient population at JOMH at any one time are Indigenous. 14

Finally, the deceased was in the facility to serve a sentence for a criminal matter. Police had arrested the deceased for disorderly behaviour at a pub, and found he had failed to pay a $300 fine for stealing a bicycle in 1993. He was charged with 'serious assault of a police officer,' an indictable offence, because he spat at the arresting officer. While the Inquiry did not comment on the charge, it seems that a complaint under the Summary Offences Act (Qld) would have better reflected the circumstances of the arrest than the very serious, indictable offence charged.

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See C. Richards, 'Deaths in Institutions: Grave concerns', Alternative Law Journal, vol 19, No.2, April 1994 examines a report from Townsville Community Legal Service which called for 'post-death investigations and inquests into the deaths of people in all forms of institutional care to be legally required' (emphasis added).

Vol 1, p 142 National Report

3 National Report, Volume 3, p.195.

4 ibid.

Cunnen and Behrendt, Aboriginal and Torres Strait Islander Custodial Deaths between May 1989 and January 1994, A Report to the National Committee to Defend Black Rights (Unpublished, 1994), p.27.

See Kirkham v Chief Constable of the Greater Manchester Police [1990] 3 All ER 246 (CA).

Report of the Inquiry under section 9 of the Mental Health Act 1974 (Qld), tabled in the Queensland Legislative Assembly on 14 May 1996 (the 'Inquiry').

Ministerial Statement to the Legislative Assembly, Hansard Record, 14 May 1996, at 999.

Inquiry, op cit, p16.

Inquiry, op cit, p125.

Inquiry, op cit, p65.

The Ministerial Statement accompanying the tabling of the Inquiry's Report indicated that this would be implemented immediately.

Inquiry, op cit, p59.

Ministerial Statement to the Legislative Assembly, Hansard Record, 14 May 1996, at 999, op cit p86.

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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