National Deaths in Custody Database Proposal

David Dungay was killed in the Long Bay Prison Hospital in 2015. He was held down onto his stomach by a six-member Immediate Action Team with knees on his back. His repetition of the words, “I can’t breathe,” echoes the cries of George Floyd and defines the callous approach taken by some authorities with coercive power. The disregard for the cries of a dying, vulnerable man provides insight into the practices used in some of the darkest corners of the country, where no one sees what happens.

The name of this restraining technique is called the ‘Prone Position.’ It had already been identified as fatally dangerous following the 2009 death of Robert Plasto-Lehner in the Northern Territory. Regardless, the same technique was used on David Dungay in New South Wales six years later. Recommendations by Coroners to stop that form of restraint were never sent to authorities in other jurisdictions, so the deadly practice has continued with no change in training.

See full proposal. 

See David Dungay Index page 

See Petition to support work 

This is a proposal for a new database system to include coronial findings on deaths in custody and recommendations from all Australian jurisdictions. It should be distributed nationwide with the responses from state and federal authorities who are affected by the recommendations. 

See responses by authorities.

Coroners’ Inquests into Robert Plasto-Lehner’s death (Northern Territory 2009), and those of Carl Antony Grillo (Queensland 2011), Bradley Karl Coolwell (Queensland 2017), and Pasquale Giorgio (Queensland 2018) reveal that in each of these cases, the causes of death were the result of being restrained in the prone position. This led to eventual suffocation from positional asphyxia. Further deaths in similar circumstances could have been avoided had the information, and possible strategies for reform, been implemented across jurisdictions.

The current coronial systems across all Australian jurisdictions present significant gaps in the collation, accessibility, dissemination and response by affected authorities of coronial reports. The Dungay family, and the wider community, stress the urgency of using the available information to prevent death.

In discharging their duties, the Coroner bears the obligation to prevent further deaths from occurring. At present, the Coroner makes recommendations for reform which are distributed to the affected authorities in their state. These reports are made available on separate coronial databases. The inclusion of government responses varies, with Queensland being the only state that specifies whether a response was required.

Data from the inquests is examined by two organisations; the National Coronial Information System (‘NCIS’) and the Australian Institute of Criminology (‘AIC’). The NCIS is intended to serve as a centralised database of deaths in custody, which includes some Coroners’ findings and recommendations. However, it is not updated regularly and has restricted access. The compartmentalisation of information leads to each Coroner existing within their own silo. This is contrary to the Coroners’ purpose of preventing further death.

The proposed database should utilise a clearinghouse model to create one central agency for information collection, classification, and distribution. The data would be collated and automatically distributed to all relevant government authorities, while also allowing for public access. It is crucial for it to be regularly updated, and require government responses to inquests, which will be searchable by catchword and report content.

It is proposed that the implementation of such a national database and follow up functions be facilitated by the NCIS and/or the AIC. The implementation of the proposed database would promote accountability among government authorities to address recurring issues that endanger the lives of incarcerated individuals. It is clear that by inducing collective learning, accessible solutions can be developed to prevent needless deaths across Australia. 

See petition to support work.

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