Inquest into the death of Esky Muller

Contributing factors

• Severe acute petrol withdrawal/intoxication on arrival at outstation
• Lack of medical assessment before admission to outstation
• No medical staff or qualified first-aid personnel at outstation
• Inadequate communications facilities (HF radio only, no telephone)
• Delay of approximately 25 minutes in establishing contact with emergency services
• Lack of advanced first-aid training (no tourniquet applied to arterial bleeding)
• Possible underlying aspiration pneumonia contributing to agitation and altered mental state
• Unregulated outstation with no oversight or safeguards
• False assertion by guardian to outstation manager that senior person had approved admission
• Admission against specific advice of experienced worker not to take deceased in that condition

Coroner's recommendations

1. All Death Certificates and Autopsy Reports reflect any connection of a death with the abuse of petrol or other inhalant
2. Establish an adequately funded consultative body to investigate and recommend means for preventing inhalant abuse, investigate treatment and rehabilitation options, and consider legislative change to assist law enforcement
3. Establish and maintain facilities for safe detoxification and rehabilitation of petrol sniffers with mandatory pre-admission medical examination, adequate communications and first-aid facilities, appropriately qualified staff at all times, and approved treatment programs
4. If outstations such as Ilpurla are to continue as rehabilitation/respite places, they must be regulated with program review and control, appropriate medical safeguards and communications facilities, and mandatory pre-admission medical examination
5. Monitor and assist petrol sniffers after return to communities from detoxification/rehabilitation facilities with appropriate ongoing care
6. Develop a tripartite strategy between Northern Territory, South Australia and Western Australia to address petrol sniffing in Central Australia including uniform data collection and dissemination of research materials
7. Commonwealth Government establish and fund rehabilitation facilities for chronic petrol sniffers in Alice Springs as a repository for information and training centre, modelled on CAAPS Darwin facility