Inquest into the death of Danny Borrak Gumana

Contributing factors

• alcohol intoxication at time of death
• cannabis use
• recent death of grandfather (one month prior)
• two previous suicide attempts in preceding weeks using same method
• changed behaviour (increased drinking, not attending work for 4 days)
• arguments with wife and cousin earlier that evening
• social isolation upon being dropped home alone
• resistance to mental health intervention
• high-risk age group and gender for suicide in East Arnhem communities

Coroner's recommendations

1. Update General Order N1 Notebooks and Diaries to instruct members to record details in notebook of any persons conveyed in police vehicle
2. Reword General Order Transport of Persons in Custody to Transport of Persons in Custody or otherwise conveyed
3. Issue general broadcast and gazettal notice advising that persons are only conveyed when detained under legislative authority or with voluntary consent, with explicit consent required for all voluntary conveyances
4. In regards to caged vehicles, conveyance of persons in cage portion will usually imply legislative authority is being relied upon and would not generally be regarded as voluntary
5. Endorse and encourage funding for implementation of Gove Peninsula Suicide Mitigation Working Strategy 2009 recommendations
6. Promote open communication and dialogue within the community regarding suicide
7. Develop programs with increased availability of indigenous mental health workers and materials in Yolngu language
8. Use alternative terminology such as healthy living or safer living instead of mental health where culturally appropriate
9. Address alcohol policy in Aboriginal communities
10. Improve community governance and leadership structures to address underlying suicide risk factors
11. Establish alternative transport solutions for patrons leaving venues late at night to reduce reliance on police as de facto taxi service
12. Consider restoration or extension of East Arnhem Night Patrol hours of operation