National Distribution of Coroner’s Findings Proposal

The death of an Aboriginal prisoner is not uncommon. David Dungay is but one of many prisoners who have perished at the hands of the State.

It is shocking to find that the events leading up to David’s death have led to deaths in custody many times before under similar circumstances, and it is more shocking that the authorities do not care to stop them. These are the deaths of Robert Plasto-Lehner (Northern Territory 2009), Carl Antony Grillo (Queensland 2011), Bradley Karl Coolwell (Queensland 2017) and Pasquale Giorgio (Queensland 2018). All of these cases involved restraint in the prone position leading to positional asphyxia and ultimately death.

Had the findings of the Coroners’ Inquests into the death of Robert Plasto-Lehner had been distributed to relevant authorities across Australia the deaths of Carl Antony Grillo, Bradley Karl Coolwell, Pasquale Giorgio and David Dungay could have been prevented.

David Dungay need not have died.

Coronial inquests into deaths in custody are mandated in every Australian State and Territory, whereby coroners are jurisdictionally imbued with the power to make recommendations within their reports. These recommendations are made with the intention of preventing future deaths and identifying systemic issues, which perpetuate further avoidable deaths.

Such was the purpose for which Deputy State Coroner Lee wrote his recommendations in response to David’s death and previous coroners wrote theirs. Unfortunately, that these recommendations have not travelled far. Coronial reports are largely utilised on a state-by-state basis with virtually non-existent dissemination between the relevant authorities of other jurisdictions.

In addressing the systematic lack of communication between the States and Territories regarding coronial findings and recommendations, we are writing a comprehensive proposal.

This proposal carefully examines the current coronial infrastructure nationally, identifies critical gaps in the system and recommends an information dissemination model that would ensure the effective and efficient distribution of life-saving recommendations around the country.

This public proposal seeks to ensure the safety of all Australians in custody and hold the government accountable, whereby in the words of Coroner Lee, “by depriving a person of their liberty, the State assumes responsibility for the care of that person”.


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