National Coroners' Recommendations Database

Brief Overview

  • In 2015, David Dungay Jr was killed by law enforcement whilst in police custody. He died from positional asphyxiation, after being placed in a prone position and entering asystole arrest (i.e. irreversible cardiac arrest). This project seeks to explore whether the NSW Coroner’s recommendations from the inquest into David’s death have been received on a national level and whether reforms have been made to implement these recommendations.
  • Justice Action is interested in this project as the demonstrated indifference to David’s death proves a failure of the authorities, and continued inaction would only lead to further preventable deaths.
  • Following our research into the issue, and the subsequent communication with national coroners, NCIS, Governor of NSW, and AIC, it has become clear current structure is lacking, and major reforms into the reporting and dissemination of key information for the prevention of future deaths in custody.

Overall Goals

  • Spread awareness of the cause of David’s death and ensure adequate action is being taken by the relevant authorities to prevent a death of this kind reoccurring.
  • Initiate and achieve the establishment of a national database through which coroners share their findings, and publish responses; minimising any chance for further deaths in custody.

Current Working Aims

  • Research current mechanisms for the national dissemination of coroner recommendations to relevant authorities
  • Gage the awareness and prevalence of positional asphyxiation within coroner recommendations more widely
  • Gage the accessibility of coroners recommendations to the public
  • Establish correspondence with coroners and govt /judicial departments responsible
  • Compiled proposal for a national database for coroners/policy
  • Continue correspondence with coroners and governors, work on winning support, and the establishment of a national database. (WIP)

Essential documents


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E ja@justiceaction.org.au
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