Inquest into the death of T. Ptjara and T. Ptjara

Contributing factors

• chronic homelessness
• chronic alcohol use disorder
• Wernicke-Korsakoff syndrome and cognitive impairment
• inadequate use of interpreters in communication
• failure to undertake meaningful decision-making regarding accommodation options
• service gaps in medication management and alcohol withdrawal care
• lack of culturally appropriate services
• exposure to cold without adequate protection after taking own leave
• use of spit hood in hospital setting
• incarceration of person unfit for custody and requiring residential care
• poor coordination between Office of Public Guardian and NDIS support services

Coroner's recommendations

1. Office of the Public Guardian implement an alert system to review, act and/or make decisions concerning homeless clients every three months of continued homelessness
2. Office of the Public Guardian review whether its current approach to case management and proactive advocacy for individual clients meets its obligations under s 21 of the Guardianship of Adults Act
3. Office of the Public Guardian commence annual reviews of clients and a process for prioritising these reviews
4. Office of the Public Guardian develop a strategy to improve culturally appropriate practices to meet the needs of Aboriginal and Torres Strait Islander people under Adult Guardianship orders
5. NT Police undertake a review including by the Cultural Reform Command of policy, procedure and training concerning visual identification of deceased and communication with Aboriginal families in the coronial process to determine whether improvements based in cultural competency can be implemented
6. Department of Corrections undertake a thorough inquiry to examine the nature and likelihood of any risk to staff from spitting, the nature and likelihood of any risk to prisoners from spit hood application and the suitability of alternatives to spit hoods, with findings well documented; use of spit hoods should be prohibited except if empirical evidence justifies continued use
7. If spit hoods continue to be available, Department of Corrections update training, policies and procedures to ensure staff are: fully informed on extent and nature of disease transmission risk based on expert evidence; fully informed on potential for physical and psychological harm to prisoners from spit hood use; fully informed concerning health risks of prisoners that are contraindicators for use; trained on alternative means to managing spitting incidents without spit hoods including donning PPE; trained to seek medical practitioners' advice before use; trained that spit hood use is a last resort; trained on requirement for swift removal if hoods used (maximum 5 minutes)
8. If spit hoods continue to be available, Department of Corrections ensure personal protective equipment is included in any kit containing a spit hood and require Corrections officers to immediately don PPE and remove hood within 5 minutes if used
9. If spit hoods continue to be available, Department of Corrections ensure every use is thoroughly reviewed by Deputy Commissioner or delegate to ensure all policy and procedure correctly applied and action taken on any breach