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“No justice, just us”: Coronial inquest leaves Dungay family without justice

None of the five correctional officers that held Dungay down were recommended for disciplinary action

CONTENT WARNING: Death in custody, racism, police violence

Disclaimer: Pranay Jha was not involved in this coverage. 

A NSW Coronial Inquest refused today to recommend five correctional officers be referred for disciplinary action, despite multiple officers pinning David Dungay Jr. down as he choked and died of cardiac arrest in Long Bay Jail. 

After nearly four years of uncertainty, the findings of the inquest into David Dungay Jr’s death were released today. 

The Coroner did not recommend correctional officers be referred for prosecution despite the family’s recommendations and multiple admissions of improper practises and use of force in the immediate lead up to Dungay’s death.

David Dungay Jr. was described to the assembled courtroom as a “proud Dunghutti warrior” who died in custody on 29 December 2015 after being pinned to the ground by six officers and crying out, “I can’t breathe” at least 12 times. 

The Inquest heard that Dungay suffered from acute schizophrenia, which resulted in auditory hallucinations and diabetes. Due to his diabetic condition, he had been eating biscuits in his cell before officers entered the cell in an attempt to remove the biscuits from him. 

Dungay was removed from his cell and placed into a new cell with camera surveillance by five members of the Immediate Action Team (IAT). There he was restrained on the bed before being moved to the floor, according to surveillance footage released during the inquest. 

His cause of death was found to be cardiac arrhythmia. 

The inquest acknowledged that positional asphyxia — a result of being held in the prone position by officers for a prolonged time — was one contributing factor in his death, although the extent to which it was the only factor was apparently unknowable. 

Aunty Leetona Dungay, the mother of David Dungay Jr, reminded the media and the assembled crowd of the continued fight for justice.

“I am his mother and I want justice, where the life of Aboriginal men is worth something. I am going to fight until I live in a country where black lives matter.”

According to Paul Silva, Dungay’s nephew, the treatment his uncle received was plainly excessive.

“When I viewed my uncle’s body, I saw a five centimeter cut on his forehead and his nose flat to his face, and a size 10 bootprint on his back,” said Silva. 

“He didn’t look like my uncle when I saw him, he looked like someone bashed, beaten up.”

In his findings, Coroner Lee noted several instances of malpractice. 

The intervention of the IAT was not necessary in organising Dungay’s cell transfer, and the move to a cell with camera surveillance was unnecessary. 

Dungay’s family maintained that his death would have been preventable if he had not been moved to a new cell. 

The Coroner also found that many of the IAT officers believed that his claims of not being able to breathe were disingenuous.

Nurse Xu who attended to Dungay also failed to hear and respond to Dungay’s cries of help.

According to the Coroner, there was a “missed opportunity” to retain all footage from the day, in addition to blood being cleaned from Dungay’s cell, which would have ultimately had profound and distressing consequences for Dungay’s family.

Questions were also raised in regards to the second injection of midazolam, a sedative drug, that was administered. It was found that the second injection was unnecessary, and also administered by a corrective officer with insufficient medical training. The officer believed the injection to be necessary due to a similar incident in 2013, in which Dungay caused harm to himself.

The Inquest was also told of the insufficiency of medical care available, but the Coroner ultimately held that the officers were simply overcome by the enormity and stress of the situation.

Numerous criticisms of the findings have been made to date. Given the extent of malpractice behind Dungay’s death, family and community members expressed immense frustration towards the insufficient training and poor procedural policy of officers involved. The Inquest also gave disproportionate attention to issues of medical malpractice, while refusing to recommend any corrective services officers for disciplinary action.

“The DPP need to get off their behinds and investigate this for criminal charges,” Silva said.

“They’re trying to say that doctors are in the wrong. No, that’s wrong. He was moved from Cell 71 to Cell 77. If he hadn’t been moved by Corrective Services, his death would have been preventable.” 

Several community activist groups met at the Coronial Court to support the Dungay family, including USyd’s Autonomous Collective Against Racism (ACAR), Fighting In Resistance Equally (FIRE), Indigenous Social Justice Action (ISJA), Aboriginal Legal Service (ALS), and Justice Action.

As the NSW Corrective Services Commissioner Peter Severin departed the courthouse, his car was obstructed by protesters from the various community activist groups, who cried shame and continued to demand that justice be done. 

When asked about the confrontation with the commissioner, Silva explained, “I asked him for a simple apology, ‘Condolences for the family?’ He shook his head and said no.” 

Since the Royal Commission into Aboriginal Deaths in Custody was released in 1991, nearly 500 First Nations people have died in custody. No police officer or correctional services officer has ever been found guilty of the death of a First Nations person. 

Members of Dungay’s family themselves pointed out that this death in custody was one of many in recent memory, and while they were disappointed and saddened at the result of the inquest, they would not stop fighting for justice. 

“It may not happen in my lifetime but my kids are going to grow up and are going to demand justice too,” said Silva.

Karly Warner, the CEO of the Aboriginal Legal Service, vowed to stand in solidarity with the Dungay family in their continued fight for justice. 

“The family is calling for accountability… you can’t imagine the grief they have gone for over the last 4 years. We have heard that a knee in his back was unnecessary… that putting him on the floor was unnecessary… that he needed time for that first injection to take effect. There are so many systemic failures here.”

Dungay’s family also  said they wanted the DPP to “get off their backsides” and fight for justice. 

All those gathered vowed to continue the fight for justice for the Dungay family and to stop black deaths in custody. 

The Dungay family’s lawyer, George Newhouse, commented on the inquest, saying: “There are some very positive reforms that the Coroner has recommended.”

“There are some very serious criticisms of prison guards and workers…this isn’t the end, we’ll be investigating every possible avenue for justice.”
The full coronial inquiry and set of recommendations can be found online.

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