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State Coroner Teresa O’Sullivan.Credit:Brook Mitchell

Today,30 years after the RCIADIC report was tabled,those words still hold such force. Self-determination for First Nations people is still lacking in this country. This unfinished business cannot be separated from anything else that is done to try to prevent the deaths of First Nations people in custody.

This is the reason I often draw on the words in the Uluru Statement from the Heart in my coronial findings when a First Nations person dies in custody:“Proportionally,we are the most incarcerated people on the planet. We are not an innately criminal people. Our children are aliened from their families at unprecedented rates. This cannot be because we have no love for them. And our youth languish in detention in obscene numbers. They should be our hope for the future. These dimensions of our crisis tell plainly the structural nature of our problem. This is the torment of our powerlessness.”

The Uluru Statement represents an invitation from First Nations people to all Australians that we cannot ignore if we are serious about preventing Aboriginal deaths in custody.

By accepting the Statement’s invitation,creating and supporting the processes that will give full effect to the Statement,and ensuring First Nations people have a say in what happens to First Nations families in relation to criminal justice issues,healthcare,and social policies,we will ultimately reduce the unacceptable numbers of First Nations deaths in custody.

NSW deaths in custody subject to coronial investigations 2008 and 2018

Since the RCIADC 30 years ago,First Nations people continue to be overrepresented in custodial populations in NSW,and continue to be overrepresented in every category of death dealt with by the Coroner’s Court.

There were 27 First Nations people who died in custody between 2008 and 2018 in NSW (where the case was subject to coronial investigations). Of those 27 deaths,57 per cent were found to be of natural causes – with the most common reasons being cardiac arrest (3),ischaemic heart disease (3) and cancer (3). Of the 44 per cent who died of external causes,the leading manner of death was intentional self-harm (10),followed by accidental overdose (3).

A total of 55 recommendations were made as a result of those investigations (53 were published,while two were subject to non-publication orders). The most common themes for coronial recommendations over that period were improving mental health treatment,additional training related to the management of healthcare issues in custody and improved medical care for inmates.

State Coroner’s Protocol for case management of mandatory inquests involving deaths of First Nations People in custody

A new protocol is being drafted,ahead of targeted consultations,for the management of mandatory inquests involving deaths of First Nations People in custody. The Protocol will sit underneath relevant Coronial Practice Notes and provide guidance to coroners in relation to the conduct of coronial investigations and inquests into First Nations People’s deaths in custody.

The key functions of the protocol will be to ensure all coronial investigations and mandatory inquests into deaths in custody of First Nations People are conducted in a timely and culturally appropriate manner;and the families of First Nations People who have died in custody are provided with timely and appropriate information and material regarding the status of the investigation into the death and the coronial process.

Teresa O’Sullivan has been the NSW State Coroner since July 2019.

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