Coronial
NThospital

Inquest into the death of Christopher Murrungun

Deceased

Christopher Wurrmerli Murrungun

Demographics

53y, male

Date of death

2015-02-12

Finding date

2016-09-02

Cause of death

Left intra cerebral and left subdural haemorrhage

AI-generated summary

Christopher Wurrmerli Murrungun, a 53-year-old Aboriginal man, died from intracerebral and subdural haemorrhage at Royal Darwin Hospital on 12 February 2015. He was found intoxicated on a public footpath in Parap, Darwin. An ambulance arrived and was ready to transport him, but Police offered to take him to hospital instead. Police transported him in a police van cage, placing him on the floor without cushioning. He was in profound intoxication with altered consciousness, unable to sit or stand independently. He had a history of previous brain bleeds from head trauma during prior episodes of intoxication. The coroner found the decision to use the police van instead of the available ambulance was unlawful and inappropriate, though did not contribute to his death. The case highlights systemic failures in the Alcohol Mandatory Treatment Act implementation—Murrungun had 60 protective custody episodes but was only assessed twice due to failures in recording protective custody episodes, triggering mechanisms, and follow-up processes.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicineneurologyintensive carecorrectional health

Error types

systemcommunicationdelay

Drugs involved

alcohol

Clinical conditions

acute alcohol intoxicationintracerebral haemorrhagesubdural haemorrhagetraumatic brain injurycerebral oedema

Contributing factors

  • Chronic alcohol misuse
  • History of traumatic brain injury and prior intracerebral haemorrhages
  • Acute intoxication with loss of consciousness
  • Use of police van for transport instead of ambulance
  • Failure to record head trauma history at hospital handover
  • Failure to record protective custody episodes systematically
  • Failure of Alcohol Mandatory Treatment scheme to engage patient

Coroner's recommendations

  1. Police Officers be reminded of the requirements that must be fulfilled for protective custody in the context of transport to hospital specifically where there is an ambulance available
  2. Police find a means to record on their database all episodes of custody including protective custody
  3. Police resolve the lack of compliance with sections 128(2A) and 128A Police Administration Act
  4. Police give serious consideration to installing a mechanism to provide Police Officers visibility into the cage area of the Police vans while transporting persons
Full text

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