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Prison Commissioner's response to recommendations

We requested for the Commissioner of Corrective Services New South Wales, Peter Severin, to consider paragraph 14.16 and Recommendations 6 and 13 made by Deputy State Coroner Lee in his inquest following the death of David Dungay. These recommendations consist of the availability of Aboriginal Inmate Delegates to assist in interactions between prison officers and Aboriginal and Torres Strait Islander inmates, and the implementation of training consisting of de-escalation techniques.

Despite the Coroner’s findings and recommendations to prevent deaths in custody, the Commissioner has responded dismissively saying “Thank you for your offer to work with CSNSW to implement these recommendations. CSNSW will contact you if that is necessary”. We attach below our exchange dated the 26th of November 2019 with the Commissioner for your reference.

Letter to the Commissioner

Commissioner's response

Meeting the Governor at Yabun

Margaret Beazley


Letter to The Honourable Margaret Beazley AC QC

Dear Your Excellency,

We are pleased you met with the Dungay Family at Yabun on the 26th of January. We have attached a photograph taken on the day.

As you are aware, the Dungay Family suffered the loss of their son David Dungay in 2015.
Mr Dungay was an Aboriginal man who died on 29th of December 2015 within the Mental Health Unit at Long Bay Prison Hospital. The Coroner’s Report stated that he died as a result of being held face down in the prone position whilst being sedated. This is called death by positional asphyxia.

Please see attached a link to our website with the background to Mr Dungay’s death.
If Mr Dungay were appropriately handled, without the use of force, he would not have suffered from positional asphyxia leading to his death.

Following Dungay’s death we were shocked to find that other deaths in custody had occurred under similar circumstances. We refer you to the Coroners’ Inquests into 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 the deceased being restrained in prone position leading to positional asphyxia and ultimately death. If 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.

In addressing this urgent public safety issue we have conducted a careful analysis of the current coronial systems across all Australian jurisdictions and have identified significant gaps in the dissemination of coronial reports. As such many preventable deaths in custody continue to occur. In response to this issue we proposed to the National Coronial Information System and the Australian Institute of Criminology the implementation of a national database of deaths in custody.

This database system would be composed of findings and recommendations to inquests into deaths in custody from all jurisdictions and these documents would be distributed to all relevant authorities and for their responses to be published. This database will address the recurring issues that commonly cause deaths in custody and will foster a collective learning across Australia, in order to prevent these needless losses of life.

Would you support the implementation of this proposal?

Additionally we requested for the Commissioner of Corrective Services New South Wales, Peter Severin, to consider paragraph 14.16 and Recommendations 6 and 13 made by Deputy State Coroner Lee in his inquest following the death of David Dungay. These recommendations consist of the availability of Aboriginal Inmate Delegates to assist in interactions between prison officers and Aboriginal and Torres Strait Islander inmates, and the implementation of training consisting of de-escalation techniques.

Despite the Coroner’s findings and recommendations to prevent deaths in custody, the Commissioner has responded dismissively saying “Thank you for your offer to work with CSNSW to implement these recommendations. CSNSW will contact you if that is necessary”. We attach below our exchange dated the 26th of November 2019 with the Commissioner for your reference.

We would greatly appreciate it if Your Excellency would support the Coroners’ recommendations for de-escalation training and the use of Aboriginal Inmate Delegates within prisons to ensure that Aboriginal inmates are given the chance to be treated with care and dignity within the Australian prison systems.

Would you support that?

Kind regards,
Nivetha Arulalan and the Team at Justice Action

31st of January 2020


Report hearing fourth day of trial October 18

Report Fourth Day of the Trial

Friday 18th October 2019 for R v Kathlin Armstrong at the Downing Centre Local Court 4.2. The hearing recommenced at 9:30am and was presided over by Her Honour Magistrate, Carolyn Huntsman. The defence team is Peter O’Brien and Tahn O’Rourke.

Aboriginal woman prisoner activist Vickie Roach addressed Kat’s supporters outside the court. In 2007 she won the constitutionally significant case in the High Court about the prisoners’ right to vote. Ms Roach said that closing WJN would be the only way to achieve justice for women prisoners at this point. It was created and driven by the consumers she said. In her view, without Ms Armstrong, the organisation no longer represented women with lived experience but highlights the opposite. Instead, it now represented white privilege and the way the system ‘steamrolls’ over women who try to make a difference from the inside. This debate takes on an intersectional feminist approach in which the system’s agents mistreat the very women they claim they are trying to protect.

IMG 2773 Vickie Roach speaking to Kat’s supporters outside the Downing Centre

Inside the court, the prosecutor took evidence from the Vice President of WJN, Ms Nicky Petrou. She has been working in the Top End Women’s Legal Centre in Darwin and as the Managing Principal Solicitor of the Darwin Community Legal Centre, but today was her last day in the job.

She said that a working group collating evidence on the case found 49 unusual transactions conducted by Ms Armstrong. Ms Petrou had never been a signatory on the accounts and had not authorised any payments on any expenditure.

Under cross examination, she agreed that Ms Armstrong was integral to the conception and running of WJN. Ms Armstrong was taking on all of the burdens of the company whilst also working to fulfil her goal of having Board members and workers that had actual lived experience of imprisonment. 

Ms Petrou agreed that Ms Armstrong declined receiving both reimbursements and a set salary and gave money she personally received to the organisation. This included $10,000 she had received for the Unsung Hero Award.

While the crux of the accusation is that she had returned money that was lent to set up the organisation, without WJN board authority, the defence pointed out that most of the funds were given by Ms Armstrong herself. Ms Petrou corroborated that Ms Armstrong had paid numerous times out of her own pocket and had consistently declined reimbursement.

The focus was next on Kat’s financial update for donations from Breakout in the second last page of the Board’s minutes on 9th October 2008. Mr O’Brien raised from the witness that Breakout and WJN had similar aims and objectives, and they had a strong working relationship. Mr O’Brien asked the witness about whether the facilities in WJN were donated by Breakout. Ms Petrou said that she was not certain but thought the “computers came from somewhere else”.

Mr O’Brien then referred to the Board’s minutes on 23th March 2009, which suggested that the financial balance in WJN did not have sufficient funds to pay back people working in the organisation. Ms Petrou emphasised that “it is our choice to be a volunteer and not to be paid”. Mr O’Brien raised the argument that the wording in the Board’s minutes saying “Kat said that when we get further funding she would be paid back,” and recording the expense as an out-of-pocket expense would have caused Ms Armstrong to have an expectation that she would be paid back. Ms Petrou said that wasn’t her view.

The cross-examination was not completed due to Ms Petrou’s request for an adjournment to finish some work for her last day, so the prosecution case still wasn’t closed.

The police attempted to make restrictions on bail include no social media reporting on the case, however the prosecutor said that such an approach would be too far reaching on the freedom of speech and that the media exposure so far was the cause of such debate.

The matter was adjourned until 19th February 2020 for an additional three days hearing of the case.

 IMG 2779

Kat Armstrong and her support team

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Return to Political and economic analysis 


Report hearing third day of trial October 17

Report Third Day of the Trial

Thursday 17th October 2019 for R v Kathlin Armstrong at the Local Court of NSW, Downing Centre, Court 4.2.

The hearing recommenced at 9:30am, presided over by Her Honour Magistrate Carolyn Huntsman. The defence team is Peter O’Brien and Tahn O’Rourke.

Kat Armstrong is accused of having returned money that was lent to set up the organisation, without the WJN Board's authority. She asserted the "legal right of claim", creating documents that authorised the return of the loans.

Natasha Thompson, the President of WJN, financial accountant and General Manager of Barnados, was called to the witness stand to discuss the various bank transactions on the WJN accounts.


IMG 2769


Prior to cross-examination, the witness said she wanted to raise issues with the prosecutor which might affect her ability to provide evidence. She and the prosecutor went out, and on returning the magistrate said that no person should behave in a manner that would hinder the witness’s ability to provide truthful evidence. This suggested that Ms Thompson was made to feel uncomfortable by people on the defence side, however all agreed there was nothing done or said to justify that.

The prosecutor’s examination of Ms Thompson resumed with the presentation of various bank statements that were accepted as evidence by the judge.

The defence lawyer Mr O’Brien commenced his cross-examination about Ms. Thompson’s experience as a board director of WJN. It transpired that she had only been a director of WJN and president of the board since January 2018 and that her involvement prior to this was as a skilled volunteer. The defence team pointed out that she had not been properly elected, to which she did not object. However she said that she felt that Kat was too inexperienced and questioned her adequacy to be President of WJN.

Ms Thompson said that Ms Armstrong had done her induction, and that she had been told that in order for payments to be made, two people would have to approve them through delegation or authorization. The fact that Ms. Armstrong had not sought approval from two parties was one of the reasons Ms. Thompson became suspicious of her activities. The defence pointed out that there had been transactions made by other board members that had not been authorized by two parties, but Ms Thompson had failed to mention those to the police. Ms. Thompson claimed that the reason was because those were not fraudulent unlike Ms Armstrong’s transactions that she believed were.

The defence observed to Ms Thompson that as part of her investigation and reading of the Board and Finance Sub-committee minutes, that she hadn’t seen any items about delegated authority. She was asked if this meant that the protocol intended and the practice actually adopted weren’t the same. She agreed.

Mr O’Brien argued that Ms. Thompson’s view on the authority of transactions made as well as her claims that Ms. Armstrong’s transactions were fraudulent merely a matter of opinion and not backed up by evidence, which is not admissible as stated within section 76 of the Evidence Act (Cth). He continued to argue that Ms. Thompson was not an expert witness since she does not have specialized knowledge in the required area, and therefore cannot make an independent assessment. The magistrate agreed.

Interestingly, Ms. Thompson agreed with the defence that WJN is an organization created for women who have previously been incarcerated, and that as part of this, it would also be run by female ex-prisoners. However she said that for the organization to be sustainable it required skilled people to manage it.

After a break for lunch, the issue of wages arose and a miscommunication was highlighted where Ms. Armstrong had asked to stop receiving wages from the Department of Justice. This was interpreted by WJN as a halt in wages altogether. This was not what Ms. Armstrong had requested thus the defense argued WJN owed Kat money but Ms. Thompson rebutted that by stating that Ms. Armstrong was a volunteer and therefore was working on a non-paid basis. The magistrate said that she would have to consider both points of view and come to a decision whether Kat was owed money.

The final witness of the day called to the stand was Helen Campbell who is the national credit manager of Print Force Australia - Hero Print, who provides print-related services to other trade companies. She provided a statement to the police stating that payments were made from Breakout Media to HeroPrint for goods and services and it was implied that Ms. Armstrong had overseen some of these transactions using funds from WJN. The witness was not cross-examined and the court was adjourned shortly after 3pm.


Report hearing second day of trial October 16

Update on Second day of trial.

R v Kathlin Armstrong at the Local Court of NSW

Report of Wednesday 16th October 2019 for R v Kathlin Armstrong at the Local Court of NSW, Downing Centre, Court 4.2

The R v Kathlin Armstrong hearing recommenced 9:30am, presided over by Her Honour, Magistrate Carolyn Huntsman.

Kat Armstrong is charged with having returned the money lent to set up the organisation without the WJN Board's authority. She asserted the "legal right of claim", creating documents that authorised the return of the loans.

Several ex-prisoners and others who had been supported by Kat’s work attended, as well as the Justice Action team. Coordinator Brett Collins had to stay outside as he will later give evidence for Kat.

IMG 2765

The cross examination of the Catherine Brennan, previous CEO of Women’s Justice Network (WJN), resumed by the Prosecution who was showing evidence containing bank statements and other documents.

The defence began their cross-examination of Ms. Brennan, focusing their initial line of questioning of the witness around her roles as CEO of WJN. These questions surrounded her credibility and context of the relationship Ms Brennan shared with Ms Armstrong.

In cross-examination, the defence raised the issue of authorisation. Referring to bank statements attached in an email exchange between Ms Brennan and Ms Armstrong, this included a document with payments to the ATO. These payments by Ms Armstrong to the ATO were dated December 2017. This document was signed by Ms Brennan. Ms Brennan denied remembering this document, however she claimed that the signature ‘looks like hers’. The witness further claimed she ‘could’ve’ been tricked into signing the document. The witness also declared ‘I did not sign it’ as she had ‘never read it before’. She broke down into tears.

At this stage the current CEO Gloria Larman called from the body of the court for an objection. The prosecutor got to her feet, looked behind her and called “objection”. The magistrate upheld the objection. Gloria Larman has attended court every day. She is paid $130,000 a year to do the job that Kat did for no pay for seven years. Instead of taking, Kat gave her prize winnings to begin the organisation.

The defence asked the witness questions regarding a Finance sub-committee meeting that had taken place September 2017. The September sub-committee minutes documented the witness’ attendance. The witness initially denied remembering attending this meeting. She broke down into tears. The magistrate adjourned for ten minutes.

During recess, there was unpleasantness in the courtroom, with the husband of the witness verbally attacking lawyer Peter O’Brien and Ms Armstrong saying: “You fucking piece of shit.”

In re-examination, the witness recalled attending the September 2017 meeting. It was for the magistrate to determine whether leave should be granted to discuss this sub-committee meeting. The prosecution claims to not have been aware of the right of claim raised by the counsel for the defence. Despite the defence’s argument that this right of claim was made known by media and in the bail application, the magistrate ruled in favour of the prosecution for the third time that day, and granted leave.

The prosecution brought forward the witness Marissa Sandler, who was a Board member of WJN between 2007 to 2014. The prosecution asked about transactions and the process of authorisation during the early days of WJN. The witness spoke about Ms Armstrong’s efforts towards WJN, who she said ‘worked very, very hard’ and had authorisation to enter agreements with creditors for daily operations, along with other daily operations.

The fourth witness brought forward was current WJN Board President Natasha Thompson. Initially, Ms Thompson was a Board member, but resigned from her position due to a “technicality”. In January 2018, Ms Thompson rejoined as President of WJN. The prosecution questioned Ms Thompson’s knowledge of the authorisation process.

The proceedings were then adjourned for the day until 9:30am Thursday 17th October.


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Report hearing first day of trial October 15

Update: first day's trial.

The case is named R v Kathlin Armstrong at the Downing St Local Court in Sydney.

The media photographed Kat, her lawyers Peter O'Brien and Tahn O'Rourke as they entered.  The Justice Action team turned out in force.

Her Honour, Magistrate Carolyn Huntsman presided. Four members of the WJN Board and management sat behind the police and prosecution.

The prosecution submitted certain items of evidence later than the 14-day deadline before the date of the hearing. Her Honour Magistrate Huntsman held that, despite this having prejudiced the defence in not allowing them to sufficiently to prepare a response to the evidence (such as bringing in expert witnesses), the evidence was of too much significance not be to admitted.

The prosecution conducted their examination-in-chief of their witness, Detective Senior Counsel David Thompson. The counsel for the prosecution mainly drew out evidence consisting of documents and statements from various sources concerning the financial transactions that took place between WJN and the people whom Ms Armstrong returned funds to.

The counsel for the defence then cross examined Detective Thompson concerning his knowledge of the administrative structure of the WJN organisation, the existence of the Finance Sub-committee of the Board, and whether this knowledge was at all material to his investigation.

The prosecutor asked the Constable questions concerning the Board of WJN, its makeup, its functioning, its members and their roles. It was determined the Constable was guided by the current board members in his investigation, he didn’t consider involvement of previous board members. The Constable didn’t include/interview the Treasurer of the company during period 2013-17 (the accused period of time). The Constable reaffirmed that he was not aware of any financial sub committee.

Catherine Brennan took the stand, previous CEO of WJN (9 months during 2017-2018). Ms Brennan did not have knowledge about how the financial decisions are made within the organisation or what they are. She was knowledgeable about members of the board and their roles and that they are volunteers. She was taught her job by Kat.
She described her CEO role and responsibilities. She described her misunderstanding about procedures to do with authorising payments/invoices. Ms Brennan’s understanding was that two people had to authorise payments. She later found out that this information was incorrect, only one signature was necessary. They examined documents of financial transactions approved by Kat Armstrong to various accounts. The crown also examined texts/email between Kat Armstrong and Catherine Brennan.

Cross examination by Peter O'Brien was about to begin but the magistrate adjourned for the day until 9:30am Wednesday 16th October to Downing St Local Court 4.2.

Index page of Womens Justice Network Takeover



Women's Justice Network Takeover

Latest News
WJN Takeover Decision!
Report hearing final day July 24. 2020

Report hearing seventh day February 21. 2020

Report hearing sixth day February 20. 2020
Report hearing fifth day February 19. 2020
Barrister Catherine Gleeson scurries away November 21
Report hearing fourth day of trial October 18
Report hearing third day of trial October 17
Report hearing second day of trial October 16 
Report hearing first day of trial 
Leaflet handout for local court October 15 
media release October 14, 2019.


The Women’s Justice Network, previously known as the Women in Prison Advocacy Network (WIPAN), was established as a grassroots community that works to raise awareness of the structural inequalities that exist for criminalised women and advocates for change to redress these injustices. Lived experience is crucial to the practical impact and success of the organisation’s functions.

Currently, however, the WJN Board is comprised only of white, middle class women from corporate backgrounds and no experience in being personally subject to the criminal justice system, contrary to the organisation’s constitutional mandate that the Board be made up of 50% ex-prisoners. This loss of prisoner input in decision making has removed its link to its community. The Board’s decision to call the police on its former CEO and co-founder Kat Armstrong is a symptom of that distance from its community culture.

Kat graduation photo

                                                                               Pictured: Kat graduating from her law degree in 2017


Kat, who was en ex-prisoner, initiated the organisation in 2007 and worked without pay for seven years as the CEO, doing all training, mentoring, fundraising, accounts and media work whilst training to be a lawyer. In 2017, Kat was found to have conducted a transfer of money disputed by the WJN Board, who then refused to meet with her, or her lawyers, or to talk with others involved to negotiate a restorative solution. Instead they complained to the police, defamed her to others and disgraced her with a front-page Herald article. Kat was charged with nine offences on 17 December, 2017. Her hearing is scheduled for mid-October 2019. 

The irony of these proceedings appear to be lost on the WJN Board; an organisation with the vision of ensuring that all women affected by the criminal justice system “are treated with dignity and respect and are empowered to secure and preserve their individual rights”, now working ruthlessly and without consideration for any alternative courses of action, to convict their very founder and a true champion for women in the prison system. 

Justice Action will be in support of Kat throughout the upcoming hearing, but in the mean time we are calling on changes to be made within the WJN. A collectivist, bottom-up approach to advocacy for women prisoners was and still is vital in ensuring the greatest level of engagement with a vulnerable community. We call on the current WJN Board to stand aside and support ex-prisoners to replace them.


See photos of Kat's achievements and awards 

Leaflet for Parliamentary Breakfast September 18, 2018: Empowering Women - Keeping Women out of Prison 

Return to Consumer Controlled Funding - Political and enconomic analysis of situation


Damien Linnane

Damien Linnane.pngDamien Linnane was born and raised in Sydney, Australia. Prior to going to prison he spent five years in the Australian Army as a Combat Medical Attendant and also completed a degree majoring in psychology at the University of New England. At the age of 29, Linnane was sentenced to ten months imprisonment for a series of crimes, including the firebombing of a home, with the sentencing magistrate finding his motivation was “vigilante action”. A member of his family had been sexually assaulted, and he aimed to get retribution against her attacker.

While in prison, Linnane wrote a crime thriller novel, Scarred, which is due to be published in late 2019. One of the other activities that got him through his sentence was self-taught art therapy. Linnane now runs a business, Vigilante Studios, doing photo-realistic portraits by commission. He has been interviewed about his experiences in prison by ABC News, ABC Radio Melbourne and Network 10. He is also a paid contributor to the Network 10 website 10 daily, where he writes about the prison system.




The Tony Liristis Case

Tony Liristis 

Mr Liristis sought orders that his solicitors supply him with a laptop while in custody in order to prepare to defend himself against current matters before the District Court. However, concerns surrounding prisoners having access to the Internet or charging their mobile phones have prevented him from having access to this technology. Peter Severin, the commissioner of the Corrective Services NSW (CSNSW) refused Mr Liristis’ request due to “security concerns.”

He was representing himself in the matter, which had to be rescheduled twice due to the inadequacy of resources. Whilst the fears about computers in cells is plausible, it restricts prisoners’ ability to have a fair trial and in turn does not comply with the explicit terms of the ICCPR.[1] In light of the violated rights, a court proceeding granted Mr Liristis access to a printer and computer in custody in order to prepare for his appeal.[2]

[1] International Covenant on Civil and Political Rights (n 1).

[2] Australian Law Reform Commission, Traditional Rights and Freedoms (Report No 129, March 2016) 219-57.

Report on Inquest 7 March 2019

NSW Coronial Inquest into the death of David Dungay
Deaths in Custody
Day 4 Wesnesday 07/03/2019


  • Dungay died of Asystole (loss of oxygen eventually leads to the heart stopping beating and leads to cardiac arrest). He was depleted of oxygen primarily (rather than ventricular fibrillation or genetic causes) and there were numerous contributory factors to his premature death.
  • There is no basis of a genetic predisposition relation to oxygen nor heart function
  • Blood sugar levels swung to very high just before he died.   Hypoglycemia can be life-threatening and can significantly add as a compounding deleterious effects to asystole.
  • Death caused by asystole is confirmed ie heart stops due to lack of oxygen, and this occurred after he struggled with CSO
  • ‘Chemical storm’ of three medications not the cause, but was likely to have affected his premature death by cardiac arrest as can increase cardiac dysrhythmia
  • Medazolam as a substance was unlikely cause of death
  • Clear signs that Dungay maintained a struggle, and the sudden nature of his death included hypoxia/asphyxia
  • Head Concussion has not been ruled out was a possible factor – Neuro-pathologist report?
  • Dungay’s neck being placed on the edge of the bed could have contributed to his death
  • Autopsy Report confirmed ‘quite marked congestion to the head’ that is due to some kinds of pressure- cant report why . This congestion pertains to head/chest pressure stopping blood flow, that then stops heart beating and person dies of cardiac arrest.
  • Autopsy Report considers cause as cardiac arrest due to hypoxia, and summarized as that any single, isolation of factors is not indicative of cause of death, however in combination, concluded is ‘maybe, uncertain’.
  • Autopsy Report isolated various negative factors that may have caused or contributed to Hypoxia such as: pressure to body areas like the neck, bruising and haemmorages, dehydration, if he was beaten up, Ketone Acidosis.

Witness 1 - Consultant Cardiologist, Associate Professor Adams

Causes of death

Dr Adams presented his evidence in relation to the factors that may have been related to or caused the premature death of David Dungay. This included analysing ECG data, wthe effect of medication he was on, the timing of when hypoxia (the heart stopped beating) was likely to have happened. In particular, he considered the factors that could potentially have deleterious effect on the electrical conductivity of his heart and caused asystole to occur. The QT Interval is the normal expected time rhythm of the heart to contract and pump blood through, and the effect of some dysfunction of the heart is marked by an increase of the QT Interval .

Key matters related to the presence or likelihood of damaging effects to Dungay’s health with regard to his QT Interval including the likelihood of effects of: stress, and either internal - such as a genetic disposition, or medically induced causes - or externally induced hypoxia (reduced or insufficient oxygen)[1].

He stated that the QT Interval can vary with Blood Sugar Levels, and that at 7 am on the day he died, BSL was 6.3 which is low but in OK limits. He noted there was a BSL swing from high to very high just before he died up to 20-25. It is ‘quite possible’ that his QT Interval would have increased with this swing.

He considered the potential of any genetic factors impacting, but concluded there were no indications of this in his or his family history, nor of him having any “Long QT Syndrome’, stating ‘Not suggesting at all that he had a genetic disposition – we don’t know’.  ECG’s show he is unlikely to have had a genetic disposition.

Based on the 2 ECG’s he said we may have increased QT Interval simply from what we understand about the medications Dungay was on, and this was likely to have affected his premature death.

He summed up that rather than any initial problem of ventricular fibrillation, Dungay most likely suffered asystole (the heart stops beating) seconds before he loses consciousness. He noted a consistency in that when Mr Ma had found a ‘very weak pulse’ it was probably a short time to asystole.

Dr Adams explained why he thought it was likely that the arrhythmia did not start when Dungay was in the first cell but rather at a later stage, an important sign being his capacity to struggle eg sustaining a struggle with five guards, his labored breathing and shortness of breath as he said ‘I can’t breathe’, getting out of the leg lock, showing ‘amazing strength’.  This indicated that the asystole occurred after the struggle, as he could not have had the capacity to struggle if it came beforehand.

Dr Adams also referred to the additive effects on increasing QT Interval due to medication, and described it as a ‘chemical storm’ that significantly would have increased the QT Interval, thus the struggle and the medication he received would have had a compounding effect.

He noted that there was food in the lungs indicative of aspiration of the stomach contents during resuscitation.

Also, he noted that congestion was in the lungs, rather than in the head. The Autopsy report showed ‘petachial haemorrages’ that can be present with prolonged straining, caused by some way that produced increased thoracic pressure that can stop the blood flow, such as congestion to the head and upper chest. These haemorrages can be caused by compression being applied to body during CPR, but he said there was no such resultant congestion was relevant to his thinking.

10:40 AM: Professor Adams in court

  • Kept stuttering when talking about his death
  • He had two theories for his death.
  • Shortness of breath in first cell
  • Shortness of breath started significantly later
  • He had little doubt he was exerting himself and after one minute he was breathing differently
  • Professor Adams thought that there were pre-disposing factors that led to David Dungay’s passing. He thinks it was side effects from psychosis medicine.
  • Whilst there was no clear cause of death (according to the autopsy), Professor Adams thinks that David Dungay had heart arrhythmia as his death was sudden and not slow (From observation that David Dungay turned blue from lack of oxygen quickly not slowly like hypoxia)
  • Professor Adams  stated restraining or struggling against someone stops the blood return.
  • Professor Adams stated the two psychosis medications together with diabetes increased the likelihood of this.
  • Professor Adams observed and stated prolonged congestion in the head, shoulders  however, has no comment.
  • He stated food on the lungs from the autopsy orbited from the stomach in resuscitation.


Witness 2 - Forensic Pharmocologist Consultant, Mr John Farrah


Mr Farrah had listened to the evidence above by Professor Adams, as well as attended to the Autopsy Report . He analysed the chemical substances and their potential involvement in Dungay’s death, including the injection of Medazolam, and the three antipsychotic drugs he was treated with therapeutically.

Mr Farrah concluded that he can make a good estimate regarding the rapid sedative, Medazolam (forced medication delivered as a intramuscular injection of a rapid sedative): that while found in the body was negligible and under the reportable level, and at a sub-therapeautic level. If Dungay’s collapse did occur within 1-2 minutes after receiving the intramuscular injection, it would have had a negligible effect.

The three anti-psychotic treatments were all at therapeutic levels or a bit higher. One drug Chlorpromosine (?) would have had a sedation effect. Zoopathixol (??) had no sedative effect but we could expect would increase QT elongation (ie adversely affect heart rhythm, as per Professor Adam report above, to which he would defer to). Mr Farrah concluded that the three antipsychotics were unlikely to be a cause of Dungay’s death.

Also, that the antipsychotic drugs taken alone would have not increased the QT Interval (ie on their own, affected his heart beat).  [Noted discrepancy: Prof. Adams stated a likely deleterious effect of these chemicals, adversely compounding on his QT Interval. However, Mr Farrah noted, he did not have a PhD nor the expertise Prof. Adams has, thus to defer to Adam’s opinion.)

It was noted that at autopsy compared to when Dungay was alive, substance levels were likely to register as slightly up, not down.

12:04 PM: Dr. John Farrah in court 

  • Stated that he has seen a media report showing the video after he prepared the toxicology part of the autopsy report
  • Toxicology segment showed that:
  • David Dungay had antipsychotic medication at therapeutic levels (level administered is really dependent on the circumstances could be administered in. For example, a person can be administered a higher than “normal” dosage for something if the person would be under strict supervision)
  • Dungay was injected with 10MG(?) of Midazolam > This dosage is considered to be on the higher end of the therapeutic range (even for David Dungay’s weight)
  • First usage of defibrillator was 5 minutes after David Dungay’s death.
  • Note : He was stuttering when questioned.
  • Dr. Farrah believes that:
  • The amount of midazolam administered contributed to Dungay’s death
  • Believes that little midazolam entered his blood (low bioavailability),  due to being injected in the gluteus muscle. The midazolam may not have entered the bloodstream properly but entered into fatty tissue instead. S response was 2 minutes.
  • Dr Farrah stated that Dungay would have a built up tolerance to  Midazolam and that it would have no significant sedative effect on Dungay. Dr Farrah suggested Chlorpromazine is known to cause this effect.
  • He also stated he didn’t have access to the video or much information in allegations to restraint.
  • Stated an average response is 45 minutes however Dungay’s was 2 minutes.

Witness 3 - Pathologist who conducted the Autopsy, Dr Bailey

The compression

Dr Bailey considered a range of factors in her Autopsy Report, including for example, bruising of the head, which was unidentified, but where concussion was a possible effect.   She summarized that in isolation factors she considered where not indicative of cause of death, however in combination, that her conclusion was that the factors considered were ‘maybe, uncertain’.

Dr Bailey detailed any noticeable damage on various regions of the body that indicate compression or damage such as bruising or haemorraging. She was unclear – ‘cant say’ - of any evidence of blood in the mouth, but there was lots of vomit, despite prolonged resuscitation. There was a small amount of haemorraging that may have occurred if head turned, but not significant enough to say was neck compression of injury. There was ‘quite marked congestion to the head’. The head and neck showed minor injuries.  

Diabeties related Ketoacidosis[2] was excluded as a cause of death, as [unspecified what level] levels were below cases she has seen.

Autopsy findings were of no pathology or ‘unascertained cause of death with several attributions’.   She can see mechanical chest and neck compression, and that increased blood pressure that led to rupture, causing haemorraging. Compression can cause blood failure to drain from out of the head, but no conclusive evidence as she can’t conclude if compression of neck was due to prone position.

She can see that compression is evident but can’t say why - eg CPR or prone position. Congestion of scalp corroborates with petechial haemmorages that blood into head but whether it is because of prone position, restraint, cardiogenic (?) shock, or maybe a combination of the above.  

She noted the CSO/IAT use of the knee ride was a potential mechanism, but can’t confirm that this was a cause of death.

Dr Bailey summarized important aspects when considering cause of death: heightened agitation as a signal of some kind of dysfunction, some obesity, diabetic, held face down, and that the effects could be cumulative. Such cumulative effects cold be where: blood oxygen level was down, plus possibly some dehydration (if had high BSL then dehydration can add to physical distress), plus placed under higher metabolic challenge.

Adding to the above, the combination of antipsychotic medication, many of which can increase cardiac dysrhythmia. She recommended we refer to the Cardiologist for this matter [and if we check above, Prof Adams did state this could have compounded and had a likely deleterious effect on heart beat rhythm].

Dr Bailey stated that the path to hypoxia with metabolic demand is already high ie affecting oxygen levels. Also, we cannot exclude that the cardiac arrest was induced by hypoxia. [See Emergency Specialist, Prof. Brown’s July 2018 evidence where he stated this as the cause of death.]

By way of summary, Dr Bailey concluded that the combination with the heightened agitation and the altercations he had with CSO, these numerous effects would have contributed to his heart going into further strain, with ‘lots of small things in combination can have an effect in this case’.

She added that Dungay’s neck being placed on the edge of the bed ‘could be contributory’.

Considering whether Dungay was beaten up, she said there are small, minor effects, but she can’t say if they were inflicted by another person in altercations, and if they were she didn’t see any signs of this as a significant contribution.

She asked herself if the police report matched with her inquiries with a neuropathologist to see if there was any brain damage/trauma - however her conclusion was not clear. She made note of rib fractures that may be common with standard CPR delivery [however positive CPR delivery was not adhered to for Dungay].    

Dr Bailey said she could ‘not see serious injury at post-morteum’, and that there were far too many contributing factors to the causes of death.  She is in no doubt that cardiac arrhythmia occurred, when being aspiration, in hypoxia or atoxia, and that she cant give certainty to know why he suddenly collapsed.

For a non-diabetic person the normal rate of ketones is between 55 – 150, as the upper limit of fasting level. She reported that the biochemical analysis of Dungay’s Ketone Acidosis shows 151 micros and concluded this was below level of Diabetic Ketosis.

1:45 PM: Dr. Kendal Bailey in court

  • Viewed the footage prior to post mortem however, didn’t have access to CPR footage of what happened before conducting autopsy. The video was provided to her by the police so she could corroborate the events that happened in the video with the injuries that were showed in the autopsy.
  • Note: Bruising on the head makes you concerned about concussions
  • Note: Injuries to the mouth might reflect compression to the nose and mouth
  • Note: Bruising is very difficult to date
  • The injuries that were shown in the autopsy report were:
  • Y shaped Laceration between the eyebrows → minor skin injury, occurred when entering the first cell where his head came into contact with a shield
  • Lesions on the forehead with bleeding on the right side
  • Purple discolouration on left eyebrow → acute bruising
  • Red-purple abrasion (scrapte type injury) on left eyebrow
  • Superficial scratch marks on the right cheekbone
  • Intramuscular hemorrhage on the jaw muscle
  • Multifocal hemorrhage to the muscle from the sternum to the neck (which helps a person turn their head)
  • Scrape injury → some skin loss to the medial surface of the right forearms
  • Both wrists showed bruising → may be due to handcuffs
  • Pink bruise on the back of the left hand
  • Bruising on both knees
  • She considers these injuries as “minor injuries if they were in isolation”
  • Dr. Bailey thinks that he passed because:
  • Heightened agitation/stress = Increased heart rate → can lead to cardiac death
  • Blood oxygen level went down = due to being compressed (abdominal organs compressed → harder for blood to drain from the head)
  • Those two were compounded by his diabetes and obesity
  • These then led for him to have a cardiac arrhythmia
  • Whilst giving her thoughts as to what the causes of David Dungay’s death, she uses the words “possibly”, “could have”, “maybe”, “not conclusive”, to demonstrate that she really isn’t sure what the causes are and doesn’t want her word to make her accountable to conclusively determine the cause/causes. For example, “the bruises on his knee could have been due to compression, but I don’t want to conclude it as that as people get bruises on their knees all the time”
  • She stated injuries don’t exclude the possibility of minor altercation with another person.
  • Dr. Bailey was asked how does an autopsy take place. She stated:
  • That the autopsy took place a day after his death
  • Steps included:
  1. Medical imaging through CT scans
  2. External examinations: to find evidence of cuts, bruises, any injury that could be found on the surface of the skin.
  3. Internal examination: involves looking at evidence of injuries on the organs and muscles of the body. She would take a sample of each tissue and look at it through a microscope
  • She stated that she needed legal permission from the coroner to perform the autopsy

Conclusions from the observation:

  • If David Dungay wasn’t physically restrained, he wouldn’t have a cardiac arrest.
  • Seems like the lawyers want ONE conclusive cause for his death (most likely lack of oxygen), but if there are a multiple amount of causes compounded, then that should be utilised as well
  • However, a death by one thousand cuts is still a death
  • Currently, the family thinks the causes were: External pressure, cardiac arrhythmia (can’t determine the cause of this)
  • Observation : Family prepared statements and media application however opessission are trying to delay by requesting to see it first. The coroner previously stated the family can provide a statement as long as they don’t use defamatory language and pin point names.
  • Questions to think about:
  • Why didn’t they show the photos from the autopsy?
  • Why are they unable to settle on the cause/causes of death?
  • Why was the evidence inconclusive?
  • Why wasn’t the Aboriginal liaison officer called to speak?
  • Why did the correctional officer breach the protocol of cell transfer (usually need permission and need to document that the cell transfer for an inmate would occur but it didn’t)?

Court adjourned 3:06pm on the 7th March 2019.


[1] Hypoxia (environmental), reduced oxygen content of air or a body of water detrimental to aerobic organisms

Hypoxia (medical), a pathological condition in which the body or a region of the body is deprived of an adequate oxygen supply

[2] [Life-threatening condition associated with very high BGL, where the blood produces acidity in body when insufficient insulin. See https://www.diabetesaustralia.com.au/ketoacidosis]

Report on Inquest 6 March 2019

Coronial Inquest into David Dungay

Deaths In Custody

DAY THREE 06/03/2019


  • Main topic of the Inquest was the Working Group (WG), established in July 2018, after the first round of Coronial Inquest proceedings. The WG is a joint effort between Justice Health (JH) and Corrective Services (CS) to create standards of procedure in relation to forced medication and restraint.
  • Main lines of questioning attempted to highlight the inadequacies of the two ‘Local Operating Procedures’ (LOPs) documents created by the WG.
  • Little demonstration of signs of the WG’s efficacy in resolving the pre-existing problems of operational procedures that were involved in Dungay’s death.
  • Questioning of the interagency working procedures between JH and CS.
  • Counsel concluded that there was no evidence of the practicalities of operations practices being addressed. 

Below is a summary of the evidence given by two key witnesses in the case.

Witness Statement 1: Sean Connelly (Head of the WG)

Sean Connelly joined JH in August 2016 and started working with Long Bay Hospital (LBH) in 2017. He had a managerial role and was part of the WG, having attended all four of the WG meetings.

The Counsel assisting the Coroner stated that it was clear that the WG was created in reaction to Dungay’s death in custody, as the major issue was Restraint Policy Procedures.


Connelly gave evidence that since he started working in LBH, two years ago, he had not witnessed any specific training on the official NSW Health Policies. However, nurses and hospital staff had undertaken training in areas derived from the NSW Health Policies, including violence prevention training.

“Doctors are responsible for their own training,” Connelly said. In terms of accountability in cases such as this, he said the end point would be Dr Ellis, the Clinical Director, who was unfortunately denied leave to be a witness by the Coroner.

There was a training day held on the 2nd of January at LBH where newly drafted LOPs were trialled. According to Connelly’s estimates, about 50% of the JH and CS staff would have attended this event. There were also plans for future training events, regarding the LOPs.

The WG

The WG had visited sites external to LBH, including the Prince of Wales and St Vincent Hospitals, which informed their drafting of the LOPs. The visits were not necessarily to the mental health wards themselves, but rather meetings with official staff at the two locations.

LOP considerations

Connelly gave evidence that the WG discussed alternatives to ‘Prone Restraint’, the physical type of restraint used on Dungay which prevented him from breathing. Alternatives included ‘soft restraints’, as opposed to the use of cufflinks. WG had not considered whether individuals other than CS officers, such as JH nurses or private security, should undertake restraint.

The LOPs drafted by the WG state that CS could undertake enforced medication after attempting to get permission from a psychiatrist. In G Ward, psychiatrists are available on-site from 8am to 4:30pm on weekdays and weekends with an on-call doctor available after hours. The LOPs do not require the on-call doctor to attend the administering of the medication. Connelly stated that there is only ‘a preference’ that they attend.

Connelly acknowledged that tension exists between JH and CS, regarding who has the final say in emergency restraint situations.

“JH and CH are jointly responsible for ensuring restraints are safe,” he stated.

Inconsistencies in the wording of the LOPs were pointed out. Connelly seemed to agree that the LOPs should explicitly state whether JH staff have the capacity to give directions, which can be followed by CS staff, regarding the safest restraint position to use in emergency situations.

Patient out-times and time-out in solitary cells

Patients in the G Ward only get one to two hours out of their cells per day. The WG did not discuss improving these conditions. Connelly stated that cells had been refurbished for the purpose of ‘time-out’. But there was no capability of using them, as they were in an area with inadequate nursing and CS observation.

Connelly’s personal reflections

Nearing the end of his questioning, Connelly stated that the nature of care in G Ward had changed after Dungay’s death in December 2015. Safe and effective care for all patients was a priority across all of LBH, particularly within the mental health ward. He regarded the partnership between JH and CS to be fundamental, believing it to be transforming into a joint process. For Connelly, the WG was an important aspect of this change.

Connelly stated that the evolving ‘simulation processes’ with joint JH and CS training are planned to begin in April 2019 with an unspecified audit to determine compliance.

He ended his examination by apologising to Dungay’s family, affirming that ‘safeguarding the processes’ undertaken by JH and CS was key in ensuring better care for their patients in the future.

Witness Statement 2: Andrew Martin Godfrey (Acting General Manager of Custodial Corrections)

Godfrey was the Secretary of the WG and the Acting General Manager of Custodial Corrections (Projects Management). He had limited ability to provide useful evidence to the Inquest and did not hesitate to inform the court of that.

Despite attending all WG meetings as Secretary, Godfrey maintained that he was not involved in their site visits or the drafting of the LOP. He had never worked in the hospital, thereby emphasising his lack of experience or knowledge in answering many of the questions put to him.


Godfrey stated that the LOPs have been in place for about 30 days. There was a trial and training day on the 2nd of January, involving a review of the LOPs and simulations on-site. He did not know the details of the content covered in the training sessions.

Godfrey believed CS would continue to work with JH and that more WG meetings were likely. He could not give any indication about when the next meeting would be or how many would be scheduled. He stated that there was a ‘reasonable assumption’ for any issues identified with the LOP, including concerns brought up during questioning in the Inquest, to be considered by the WG.

The Coroner conceded that this witness was not best placed to answer questions about how the LOPs would be practically implemented by CS, being the reason he was called to give evidence. The next witness in line had already been sent home earlier in the day. The day’s proceedings were therefore adjourned early.


In the afternoon of Day 3 of this Inquest, substantial time was spent arguing about which WG member was a suitable witness as well as the Dungay family’s request for Dr Ellis. Not only was Dr Ellis a WG member, he also possessed considerable clinical experience in areas such as training psychiatrists and psychologists. JH and CS legal representatives insisted Connelly and Godfrey to be suitable witnesses for cross-examination but Godfrey proved unable to answer many questions put to him.

It seemed especially unfortunate that Dr Ellis had been denied as a witness in the Inquest because his name was mentioned quite often in the questioning that occurred today. It is likely that Dr Ellis could have been able to offer greater insight as a witness.


Please see DAY FOUR for a continued recount on this Coronial Inquest.

Report on Inquest 5 March 2019

Coronial Inquest into David Dungay

Deaths In Custody

DAY TWO 05/03/2019


  • Lack of Medical Intervention: Categorised within forced medication
  • Lack of training for authoritative Correctional staff dealing with prisoners
  • Failure in identifying the ramifications associated with the medical intervention towards David Dungay
  • Errors in medical judgement

Below is a summary of the evidence given by three key witnesses in the case

Witness Statement 1 – Dr Ma

Dr Ma was an accredited medical practitioner who initially carried out the forced medical treatment on David Dungay. Dr Ma was aware of the medical condition of David Dungay and has intervened in this treatment.

Identifying traits in patients medical condition:

Dr Ma reiterates that the patient has ‘impaired judgement.’ From this case it would be relevant to consider that David Dungay’s behaviour and medical diagnosis is relevant in proving the mitigating factor of this case; as he acts impulsively rather than rationally due to the mental impairment associated with his medical condition.

Errors in medical judgement

There was no accredited third party auditing service provided in regards to emergency training practices. In addition, professional staff failed to de-escalate the patient’s aggravated behaviour, resulting in a breach of their level of care. In regards to this case, there was a failure in liaising directly with professionals within the appropriate hierarchy stipulated, resulting in a lack of confidence within the Health Department. David Dungay’s state of vulnerability was exacerbated by the neglect of staff officials in making appropriate observations of his physical state.

In regards to the CPR medical training prerequisite, Dr Ma further corroborated that it was an “Appalling attempt at resuscitation,” and that it was certainly not up to his standards.

The liability falls against Dr Ma, as the medication to be administered was beyond the duties of the Nurses, yet Dr Ma still instructed them to administer it. The argument in which defends the initial purpose of Dr Ma’s actions is that these nurses were highly experienced and he believed that they could undertake such tasks. Dr Ma believed that his area of control was in reading the notes and assessing the circumstances.

Witness Statement 2  Chief Trainer for Justice Health Staff; Mr Sontag

Mr Sontag is affiliated in the field of health and is a Chief Trainer for Justice Health Staff, including nurses. Mr Sontag was involved in the case of David Dungay, whereby he administered the training and education of the Nurses. Sontag is involved in various training programs; such as the ‘Myrtle Program’ and other various initiatives.

Lack of training and education for Nurses

The lack of administering the appropriate approach to training and education was evident, seen through the inadequate procedures undertaken for CPR on Mr David Dungay. This is highlighted through the role of Nurse Maharja, who was cross- examined about the training content on the 04/03/2019.

The lack of induction training and education is clearly indicated through the inadequate intervention in possibly saving David Dungay’s life. Mr Sontag confirmed that the video evidence showed that there was difficulty in air passage. He confirmed that the cap was left on the suction device, as well as the neglect in examining who was responsible for this. Mr Sontag reiterated the notion that there is a prevalent issue in the structure of leadership within nursing practices, which demonstrated a lack of confidence.

Compliance with Australian Standards

Mr Sontag affirmed that there is no audit of medical emergency training practices, as he stated that these incidents are quite rare.

Witness Statement 3 – Ms Sheehan

Ms Sheehan is Deputy Director of Midwifery and Custodial Services. She presented existing health policies on Enforced Medication.

Policies for Medical Practices

Ms Sheehan stated policies in relation to PRN medical patients, the need for de-escalation actions by nurses, and the Enforced Medication and the Emergency sedation policies and practices. She recommended for these policies to be brought in line with current NSW Health Policies.

Ms Sheehan further gave evidence that a nurse could make a decision in regards to intramuscular injection of midazolam on a PRN patient such as Mr David Dungay.


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