Meeting the Governor at Yabun

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

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