Aboriginal deaths in custody

An Aboriginal man has died in a Melbourne prison just hours after returning from hospital.

The ABC understands the 32-year-old man was taken to St Vincent’s Hospital on Wednesday morning for treatment.

He was then brought back to the maximum-security Port Phillip prison, where he died in the medical unit on Wednesday night.

A spokesperson from the Department of Justice and Community confirmed the man died on Wednesday.

“It is with great sorrow that Corrections Victoria acknowledges the passing of a prisoner at Port Phillip Prison,” the spokesperson said.

“As with all deaths in custody, the matter has been referred to the coroner, who will formally determine the cause of death.”

Premier Daniel Andrews said both the coroner and Corrections Victoria would conduct a full review into death.

A statement was posted to the Corrections Victoria website late on Friday afternoon, saying: “We recognize that all deaths in custody have impacts on family members, friends, victims and the broader Aboriginal community, and we’re working to ensure they are provided with the support they need.”

Victoria’s corrections system was heavily criticized during a recent inquest into the death of Aboriginal woman Veronica Nelson, who died alone in her cell despite repeatedly calling out for help.

A St Vincent’s spokesperson offered the hospital’s condolences and said it would comply with the coronial inquest.

Push for uniform services across Australia

Federal Attorney-General Mark Dreyfus told ABC Radio Melbourne he wanted all states to adopt uniform custody notification services.

A close up shot of Mark Dreyfus wearing a suit and tie. — Attorney-General Mark Dreyfus says all corrections centers are run by Australia’s states and territories.(AAP: Mick Tsikas)

He said national implementation of the support services would enable Aboriginal people in custody to speak to lawyers, family members and support services.

“We’ve made a commitment in the election to assist families with coronial inquiries with the hope that if these deaths in custody are examined, we will learn more about how they can be prevented,” he said.

In 1991, Australia’s Royal Commission into Aboriginal Deaths in Custody warned the arrest of Aboriginal people should be a last resort and that prison staff should be trained to recognize the signs of deteriorating health.

There have been more than 500 deaths in custody since the commission.

Co-chair of the First Peoples’ Assembly of Victoria Marcus Stewart said the figure showed that changes were long overdue.

“[It’s] 500 too many. I have no confidence that the system is working,” he said.

“I think the system is rotted and corroded to its core and we need systematic reform, structural reform.”

Marcus Stewart, Co-Chair of the First Peoples' Assembly of Victoria — Marcus Stewart says the First Peoples’ Assembly of Victoria is calling for a truth-telling process to address deaths in custody.(Supplied)

He said mechanisms such as the Yoorrook Justice Commission, a truth-telling process, needed to be put in place so treaty could deliver reforms.

Mr Stewart said he was in favor of Mr Dreyfus’ suggestions of national custody notification services.

“It’s a bottom line responsibility that the government should be doing as a normal practice, and it’s kind of disgraceful … that in 2022 we’re talking about that being introduced,” he said.

“We see you, we hear you and we notice the inaction you’re taking on Aboriginal deaths in custody.

“Step up and take responsibility.”

A 19-year-old Aboriginal man’s death would likely have been prevented if multiple state authorities had not failed to arrange a life-or-death medical appointment, according to the WA state coroner.

Aboriginal and Torres Strait Islander readers are advised that this story contains an image of a person who has died.

Mr Yeeda, whose first name is being held for cultural reasons, died on May 3, 2018 at the West Kimberley Regional Prison near Derby.

The Miriuwung Gajerrong man was six weeks away from being released when he died from rheumatic heart disease after a game of basketball at the facility.

“He was looking forward to life,” said his mother Marlene Carlton, who released a written statement through the National Justice Project.

“He wanted to do his time so he could come out and live with his dad on a station and work with horses.”

According to the state coroner’s findings released this week, Mr Yeeda had rheumatic heart disease and had a referral to see a cardiologist about getting heart surgery.

However, an appointment for Mr Yeeda was never made.

Surgery likely would have prevented death

Based on an inquest held in September, the WA coroner concluded the young man would likely have been told he needed urgent heart surgery if he had made the appointment.

“If Mr Yeeda had undergone aortic valve replacement surgery, it is likely that his death would have been prevented,” a summary statement from the coroner said.

A picture of Mr Yeeda smiling on a horse, holding his hat in the air with Kimberley rock formations behind him — The WA coroner has found Mr Yeeda’s death would likely have been prevented if not for failings in the health and justice systems.(Supplied: National Justice Project)

The coroner added that the WA Country Health Service bore the ultimate responsibility for the referral not being actioned, while the Department of Justice missed an opportunity by not having a computer-based tracking system to make sure urgent prisoner referrals were not missed.

“The WA Country Health Service feels deeply for the deceased’s family,” a spokesperson for the service said.

“While we can never replace their loss, we are working closely with all concerned on the recommendations outlined by the coroner.”

The Department of Justice said it acknowledged the findings of the coroner.

“All deaths in custody are taken seriously and systems and processes will be reviewed in light of the coroner’s recommendations,” the department said in a statement.

WA Cardiology also missed a number of opportunities to assist, according to the coroner.

The service has been contacted for comment.

Coronar’s recommendations

The coroner recommended that the Department of Justice work together with the country health service to improve the exchange of information about the status of referrals, and address tracking system delays created by a lack of resources in the department.

The third and final recommendation was for the department to investigate the feasibility of creating a list that would alert prison officers if an inmate was unfit for sport or work.

Mr Yeeda had been in custody for about one year when he died, having been taken into the facility on May 5, 2017.

He required regular medication and monitoring for heart damage he experienced as a young child, when he had rheumatic fever.

He had surgery for an aortic valve repair when he was a child but it was not a cure for his rheumatic heart disease.

Mr Yeeda was supposed to have monthly penicillin injections but was occasionally resistant to having them.

Arrangements for Mr Yeeda to have heart surgery had previously been made in 2015, but those surgeries were canceled because consent had not been provided by him, or on his behalf.

“However, the fact that there had been no past consent did not mean there would be no future consent,” the coroner wrote.

According to the findings, Mr Yeeda had agreed on December 5, 2017 to see the visiting cardiologist but the appointment was not made.

He died about five months later.

Ms Carlton said her son’s death should have been prevented.

Concerns about racism, lack of cultural care

“There was a lack of communication between the prison and me – if anything happened to him, they should have called me, but they didn’t,” Ms Carlton said.

“There should be a better system to monitor their [the inmates’] health, and they need people in the prison who understand Indigenous culture and health [requirements].”

George Newhouse, the principal solicitor and director of the National Justice Project, said more needed to be done to ensure culturally safe health care in prisons.

“The coroner has failed to address the systemic racism in WA’s justice and healthcare systems which led to Mr Yeeda’s death,” Mr Newhouse said.

Professor Juanita Sherwood, a Wiradjuri woman and board member of the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives, said prison staff should have followed national guidelines for managing rheumatic heart disease.

“These guidelines are easily accessible, and prison and health staff should have known better because we all know it’s a big issue for Aboriginal and Torres Strait Islander communities that needs to be managed well,” she said.

“The lack of treatment and follow-through reveal a negligent treatment of Mr Yeeda.”

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