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23-30 November, 2004 and 14 March 2005
South Australian Coroner’s Court
Coroner Wayne Chivell
1. This inquest concerns the deaths of four people, Kunmanara Ward who died on 22 May 2003, Kunmanara Ken who died on or about 19 December 2003, Kunmanara Ryan who died on 2 March 2004 and Kunmanara Cooper who died on 24 March 2004.
2. Kunmanara Ward, aged 19 years, died on 22 May 2003, by hanging himself from the ‘monkey bars’ at the playground at Indulkana. He had been sniffing petrol, and had been angry and upset that day.
3. There is no evidence that any other person played a part in Kunmanara Ward’s death.
4. Kunmanara Ken, aged 35 years, died on or about 19 December 2003 as a result of exposure. He had walked away from his sister at Amata earlier that day, and was not seen again. The maximum temperature on 19 December 2003 was 42ºC.
5. Kunmanara Ken had severe organic brain damage as a result of sniffing petrol since he was a boy. He had been exhibiting signs of neurological damage since his early 20’s and by the time he died it was estimated that he had a mental age of about 3 years. He had no life or survival skills, he was unable to look after himself, and he would forget to eat and drink. He was so intellectually disabled that people would put red cordial in a tin and he would go around the community sniffing it thinking it was petrol.
6. South Australia Police (‘SAPOL’) were advised of Kunmanara Ken’s disappearance during the evening of 19 December 2003. Initial searches were conducted, but it was not until Sunday 21 December 2003 that the matter was reported to senior personnel, and a full air and ground search was arranged. This commenced on 22 December 2003. The Community Constable and community members had continued to search unassisted in the meantime.
7. It was not until 23 December 2003 that Kunmanara Ken’s body was found by relatives in an area known as Telstra Hill, near Amata, within sight of the lights of the town. This lack of police response for more than two days is a matter of grave concern.
8. Senior officers of SAPOL have acknowledged that the response was inadequate, and steps have been taken to ensure that this will not be repeated. It is to be hoped that these steps have been effective.
9. There is no evidence that any other person played a part in Kunmanara Ken’s death.
10. Kunmanara Ryan, aged 25 years, died on 2 March 2004 by hanging himself from a tree near Mimili. He had a history of mental illness in the form of depression, and had recently been assessed by a consultant psychiatrist. He had received a good standard of psychiatric care. There is no evidence that Kunmanara Ryan had been sniffing petrol at any relevant time immediately before he died. His psychiatrist, Dr Cord-Udy, had expressed concern regarding his ongoing drug abuse.
11. There is no evidence that any other person played a part in Kunmanara Ryan’s death.
12. Kunmanara Cooper, aged 27 years, died on 24 March 2004 by hanging himself from a tree near Mimili. He had been sniffing petrol prior to his death.
13. Kunmanara Cooper had recently been imprisoned at Port Augusta, then transferred to James Nash House, a secure psychiatric facility. Upon release, he travelled to Whyalla where his mother lived. He was arrested again, but was not imprisoned further. He was released on a bond, a condition of which was that he live in Pipalyatjara. He was assisted by the Department for Correctional Services to travel. He was probably on his way to Pipalyatjara, and stopped off in Mimili on the way, perhaps waiting for a lift.
14. Kunmanara Cooper’s family were preparing to travel to Indulkana to pick him up when they heard of his death.
15. The standard of psychiatric care provided to Kunmanara Cooper in James Nash House was very good, although limited by a lack of qualified Anangu interpreters, and difficulty liaising with Anangu community members. These are intractable difficulties, and I accept that the Department of Health are doing their best to find solutions.
16. Many of the issues associated with Kunmanara Cooper’s case could not have arisen if there had been a correctional facility available on or near the Anangu Pitjantjatjara Lands. It is impossible to know whether his death could have been prevented if such a facility had existed in March 2004, but it is reasonable to suggest that it may have been.
17. There is no evidence that any other person played a part in Kunmanara Cooper’s death.
18. There has been a marked increase in suicidal and self-harming behaviour on the Anangu Pitjantjatjara Lands since March 2004.
19. Petrol sniffing is one of several factors contributing to this phenomenon. Other factors include substance abuse (petrol, alcohol, cannabis and other drugs), interpersonal violence (including domestic and sexual violence), family conflict, mental illness, motor vehicle accidents and many others.
20. I referred to a variety of socio-economic factors including poverty, hunger, illness, low education levels, unemployment, boredom, and feelings of hopelessness in findings I wrote following inquests conducted in 2002 into the deaths of three people on the Anangu Pitjantjatjara Lands resulting from petrol sniffing. I commented
That such conditions should exist among a group of people defined by race in the 21st century in a developed nation like Australia is a disgrace and should shame us all.
Those conditions still exist.
21. I heard extensive evidence in the 2002 inquests about the Government responses to petrol sniffing as an issue. I heard about the Anangu Pitjantjatjara Lands Inter-Governmental Inter-Agency Collaboration Committee (‘APLIICC’), Tiers 2 and 3, framework agreements, the Central Australian Cross Border Reference Group on Volatile Substance Use, the Petrol Sniffing Task Force and the COAG trial.
22. On 30 September 2002, the South Australian Cabinet transferred responsibility for APLIICC to the Department for Aboriginal Affairs and Reconciliation (‘DAARE’). In retrospect, this was a mistake. DAARE did not have sufficient resources, power and authority to drive major change in key government agencies. Political instability in the Anangu Pitjantjatjara Executive, the body with which the Government had decided to deal in relation to service delivery, also hindered effective action.
23. In February 2004, it became apparent that the 2003/2004 budget allocation of $12m, to be spent over four years, remained largely unspent.
24. Coincidentally, on 16 February 2004, notice was issued of an inquest into the deaths of Kunmanara Ward and Kunmanara Ken.
25. There were four deaths by hanging on the Anangu Pitjantjatjara Lands in March 2004, including those of Kunmanara Ryan and Kunmanara Cooper.
26. Although some action had been taken prior to this time, particularly by SAPOL, these events appear to have galvanised the South Australian Government into more urgent action. Action by SAPOL, Mental Health Services, and in the area of domestic violence was taken forthwith. Responsibility was transferred to the Department of the Premier and Cabinet, a more powerful and influential department, which reports through its Chief Executive Officer to the Premier. I have no doubt that this has resulted in much more concerted action. The Aboriginal Lands Task Force (‘ALTF’) was established which took over the role of APLIICC. A Coordinator of Government Services was appointed (although he and his successor have both since resigned). The budget allocation was increased by a further $12.96m, over four years. A Strategic Plan was developed, and 27 substantial projects were initiated.
27. I have been told about the formation of Tjunjunjku Kuranyukutu Palyantjaku, a widely representative peak body, to deal with ALTF on the planning and overseeing of services, and responding to issues raised by the ALTF.
28. It is very unfortunate that the optimism expressed by South Australian Government representatives during the 2002 inquests did not translate into the ‘prompt, forthright, properly planned, properly funded action’ which was called for, until March 2004. I received similarly optimistic evidence this time, and it is to be hoped that better results will be achieved. The early signs are good. The impetus achieved thus far must be maintained in the medium and long-term. If these efforts ‘run out of steam’ again, further deaths and misery can be expected.
29. It is a great pity that, even after the 2002 inquests during which the failure of similar programs was considered, youth worker programs were set up on such an adhoc and unplanned basis, without regard to previous experience, and with insufficient training and supervision of the workers. It is to be hoped that the review of these programs will result in a more coordinated and professional youth worker program being established. It is also to be hoped that the review will enable the Department of Families and Communities to avoid the mistakes of the past being repeated again.
30. Neuropsychological testing of chronic petrol sniffers has been conducted to a limited extent on the Anangu Pitjantjatjara Lands so far, and has shown very disturbing results. Further testing should be carried out so that all people with suspected brain damage can be identified and appropriate programs can be devised for them.
31. The allocation of funding for the establishment of outstations/homelands for the rehabilitation of petrol sniffers is to be applauded. However, the long-term success of such projects will require commitment from Anangu, but also commitment, encouragement and support from other workers, just as Mr Stojanovski’s role was instrumental in the success of the Mount Theo program in the Northern Territory.
32. While the development of ‘Opal Unleaded’ fuel is a welcome development, it should not be seen as a panacea for petrol sniffing. Action will be required to prevent the development of a black market in ‘sniffable’ petrol, and to develop adequate security measures to prevent theft of the new Avgas, which will be rendered ‘sniffable’ once it becomes unleaded.
33. The Department for Correctional Services has developed a new ‘service model’ for services to the Anangu Pitjantjatjara Lands which involves a significant increase in staffing levels. If successful, this will increase the range of sentencing options available to Courts sitting in the Anangu Pitjantjatjara Lands. A review of the performance of the new model will be undertaken in early 2005. Changes must be made if the new model does not meet expectations.
34. In light of the South Australian Government’s decision that a joint secure care/correctional facility will not be developed, it is not possible for me to form definite conclusions or recommendations about where a correctional facility should be established. Obviously, much will depend upon the availability of funding, political will and interstate cooperation. If, in the final analysis, it is decided to adopt the Cross Border Justice Project approach, then something is to be gained by Anangu offenders being imprisoned in Alice Springs rather than in Port Augusta or in Adelaide. Ideally, in my opinion, such offenders should be dealt with on the Anangu Pitjantjatjara Lands where they can be dealt with in a culturally appropriate way, retain ties with their communities, and are not given the opportunity to be led astray in Alice Springs. However, if that is not feasible, then so be it.
35. I note that funding has been allocated for the construction of a secure care facility on the Anangu Pitjantjatjara Lands to provide the opportunity for sobering up, detoxification and rehabilitation of substance abusers. This is not to be a correctional facility. The facility is still in the design stage, and there are still many outstanding issues. The location of the facility, its staffing, resourcing, whether it will cater for children and/or adults, men and/or women, detainees and/or voluntary patients, all remain to be resolved. I can only encourage the ALTF to persist in its efforts to achieve a useful outcome.
36. The establishment of night patrols is still in the very early stages, and should be assisted by the increased police presence on the Anangu Pitjantjatjara Lands.
37. It would seem that the role of the CYFS (‘Child Youth and Family Services’) in child protection on the Anangu Pitjantjatjara Lands is being carefully monitored, and should be greatly enhanced by the appointment of the Coordinator of Government Services once the position is established, and accommodation and other issues are dealt with. CYFS has the potential to play a very valuable role in the prevention of self-harming behaviour on the Anangu Pitjantjatjara Lands, both in addressing the underlying socio-economic circumstances in which such behaviour occurs, and in the provision of preventative and diversionary strategies when it occurs.
38. I would urge the Department of Health and the Department of Families and Communities to ensure that the Coordinator of Government Services should reside on the Anangu Pitjantjatjara Lands, for all the reasons discussed in the 2002 findings.
39. To date, the development of crime prevention strategies has been limited by the lack of police resources available. Once the further resources which have been allocated are in place on the Anangu Pitjantjatjara Lands, the development of these strategies will be much easier. The success of the Blue Light Discos already conducted is very encouraging and is to be commended.
40. The provision of disability services on the Anangu Pitjantjatjara Lands remains problematic. I accept the assurances made that the Disability Services Office are keen to improve the level of service provided. Initial attempts to provide services with Anangu employees through community councils were ill-considered and failed. Further lengthy consultation and negotiation processes have taken place since then, and Anglicare Central Australia is about to start a major program of service delivery in 2005. Problems of service overlap between providers are still to be sorted out.
41. This represents another example of Government agencies embarking on poorly-planned enterprises without learning from the failures of the past. In particular, it cannot be expected that Anangu can deliver relatively sophisticated services to severely disabled people without proper training, supervision and support, at least until they acquire the necessary skills and experience to maintain the level of service required.
42. This is another area where I was given optimistic evidence about what was about to happen, despite little having been achieved since the 2002 findings. One can only hope that this optimism is justified, in view of the fact that there are other Anangu with a similar level of disability to that of Kunmanara Ken, and who remain just as much at risk.
43. The steps taken to improve incentives to assist in recruiting both public sector employees and police officers to remote areas including the Anangu Pitjantjatjara Lands represents a considerable improvement. Further, the approach taken by SAPOL in relation to the difficulties in securing appropriate accommodation is also to be commended. It seems that an aggressive approach towards obtaining appropriate housing facilities for workers on the Anangu Pitjantjatjara Lands will be the one likely to produce success, as will an approach which fosters the belief that service in remote areas will be valuable to an officer’s career.
44. The SAPOL response to the 2002 findings has been prompt and comprehensive, perhaps more so than any other agency. Action had been taken prior to the deaths in March 2004, and further action has been taken since. The substantial increases in police officer numbers on the Anangu Pitjantjatjara Lands, substantial increases of reports and apprehension rates, the commitment to placing resident officers on the Anangu Pitjantjatjara Lands and the community development work are all to be commended. These actions should go a long way towards providing Anangu with the degree of safety and protection to which they are entitled as citizens of Australia.
…
13.1 In the 2002 findings, I made a number of recommendations which I thought may prevent, or reduce the likelihood of, a recurrence of an event similar to the deaths being considered (see Section 25(2) of the Coroners Act, 1975). Tragically, with the exception of Kunmanara Ryan, the deaths now being considered are so connected with petrol sniffing that they must be considered ‘similar’ to the deaths being considered in the 2002 inquests. Indeed, since the 2002 findings, the problem of petrol sniffing has become worse, not better.
13.2 To that extent, either the recommendations I made in 2002 were inappropriate, or they have not been effectively implemented. With the exception of the secure care/correctional facility recommendation, it has not been suggested in this inquest that the 2002 recommendations were inappropriate. It has therefore been necessary to consider the extent to which they have been implemented.
13.3 Detailed planning has been done, and substantial funding has been committed. However, with the exception of SAPOL and the Department for Correctional Services, most of the necessary remedial action is yet to be implemented.
13.4 In those circumstances, it is appropriate that I should repeat the general recommendations I made in the 2002 findings. Making due allowance for the fact that Anangu Pitjantjatjara Lands Inter-Governmental Inter-Agency Collaboration Committee has been replaced by the Aboriginal Lands Task Force, I now recommend:
1. That Commonwealth, State and Territory Governments recognise that petrol sniffing poses an urgent threat to the very substance of the Anangu communities on the Anangu Pitjantjatjara Lands. It threatens not only death and serious and permanent disability, but also the peace, order and security of communities, cultural and family structures, education, health and community development;
2. Socio-economic factors such as poverty, hunger, illness, lack of education, unemployment, boredom, and general feelings of hopelessness must be addressed, as they provide the environment in which substance abuse will be resorted to, and any rehabilitation measures will be ineffective if the person returns to live in such conditions after treatment;
3. The fact that the wider Australian community has a responsibility to assist Anangu to address the problem of petrol sniffing, which has no precedent in traditional culture, is clear. Governments should not approach the task on the basis that the solutions must come from Anangu communities alone;
4. The Commonwealth Government, though the Central Australian Cross Border Reference Group, and the South Australian Government through the Aboriginal Lands Task Force, should accelerate their efforts to find solutions to these issues and get beyond the ‘information gathering’ phase forthwith. They should use the extensive knowledge, published material and professional expertise that is already available;
5. It is particularly important that Inter-Governmental coordination of approach be a high priority in order to avoid the fragmentation of effort and confusion and alienation of service-providers which are features of current service delivery to Anangu communities;
6. Commonwealth and State Governments should establish a presence in the region, if not on the Anangu Pitjantjatjara Lands then at least in Alice Springs, of senior, trusted officials, in order to develop local knowledge, personal relationships with service providers and receivers, and some expertise and experience in cross-cultural issues, rather than relying on infrequent meetings with ever-changing officials in order to communicate with Anangu. Such officials should be invested with sufficient authority to manage and assess programmes on an ongoing basis, so that service providers can have a line of communication with the funding body, and some certainty as to future arrangements;
7. Many of the strategies for combating petrol sniffing which have been tried in the past should not be discarded simply because they failed to achieve permanent improvements. Some of them might be regarded as having been successful for as long as they were extant. For any strategy to be successful will require broad Anangu support. Most strategies will fail unless they are supported by others as part of a multi-faceted approach. Strategies should be aimed at primary, secondary and tertiary levels, as I have outlined in these findings;
As to specific issues, I make the following further recommendations:
8. The Commissioner of Police should consider whether all SAPOL personnel in rural and remote areas should receive the type of training described by Superintendent Bristow at paragraph 3.56 hereof, in order to ensure that search and rescue operations in such areas are timely and adequate;
9. The South Australian Government should consider how the paucity of Anangu interpreters might be addressed, and how liaison with Anangu community members on behalf of a person detained in a corrective or psychiatric institution might be improved;
10. The Premier, in consultation with the Minister for Correctional Services, the Aboriginal Lands Task Force and the Central Australian Cross Border Reference Group, should consider as a matter of urgency how the development of a culturally appropriate correctional facility, on or near the Anangu Pitjantjatjara Lands, or as part of a tri-state development at some other reasonably proximate location, might be accelerated;
11. The Aboriginal Lands Task Force should persist in its efforts to address the outstanding issues so that an appropriate secure care (as distinct from correctional) facility might be developed at the earliest possible opportunity;
12. The Department for Families and Communities should consider, in the light of Mr Kay’s review, how it might establish a properly structured, funded and coordinated youth worker program for the Anangu Pitjantjatjara Lands;
13. The Disability Services Office and the Department of Families and Communities extend the level of neuropsychological testing of chronic petrol sniffers throughout the Anangu Pitjantjatjara Lands so that the full extent of disability, flowing both from petrol sniffing and otherwise, might be ascertained and the appropriate level of disability services can be provided;
14. Action already taken in relation to outstations/homelands should be further supported so that more such projects can be established on the Anangu Pitjantjatjara Lands for the benefit of all Anangu;
15. The Commonwealth Government should continue to support the availability of ‘Opal Unleaded’ fuel on the Anangu Pitjantjatjara Lands, and consider what security measures will need to be taken when the constituents of ‘Avgas’ become sniffable;
16. The Department for Correctional Services should consider, in light of the review of its new service model, what further steps need to be taken to provide an adequate level of service in the Anangu Pitjantjatjara Lands;
17. The efforts already made towards to the development of night patrols on the Anangu Pitjantjatjara Lands should be further encouraged and developed;
18. The Department of Families and Communities should consider how the role of the Children, Youth and Family Services Unit in relation to children at risk on the Anangu Pitjantjatjara Lands might be enhanced so that underlying socio-economic circumstances might be addressed, and appropriate preventative and diversionary strategies might be developed;
19. The Department of Health and the Department of Families and Communities should ensure that the new Coordinator of Services should reside on the Anangu Pitjantjatjara Lands;
20. Once it is fully established on the Anangu Pitjantjatjara Lands, SAPOL should further develop crime prevention strategies;
21. The Disability Services Office should closely monitor the adequacy of the disability services program to be delivered to Anangu in 2005, and to ensure that any shortfall in service delivery is urgently addressed;
22. SAPOL should persist with the efforts it has made so far to provide appropriate levels of personnel and accommodation on the Anangu Pitjantjatjara Lands as was outlined by Superintendent Bristow and Deputy Commissioner White, and to further develop strategies for providing a safe and secure community for Anangu to live in.
23. The interventions described above must be implemented as part of an overall multi-faceted strategy, and not piecemeal, as they are interdependent and stand a high chance of failure if they are introduced separately;
24. The recommendations of the Royal Commission into Aboriginal Deaths in Custody should be re-examined by both Commonwealth and State Governments as a check to assess the degree to which those recommendations have still not been implemented.
The full Inquest Findings are available on the website of the South Australian Courts Administration Authority <http://www.courts.sa.gov.au/courts/coroner/findings/findings_2005/ward_ken_ryan_cooper.finding.htm> .
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URL: http://www.austlii.edu.au/au/journals/AUIndigLawRpr/2005/74.html