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.

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