Coronial
QLDother

Mulrunji

Deceased

Cameron Francis Doomadgee (known as Mulrunji)

Demographics

36y, male

Coroner

Clements

Date of death

2004-11-19

Finding date

2006-09-27

Cause of death

intra-abdominal haemorrhage due to rupture of liver and portal vein

AI-generated summary

Mulrunji (Cameron Francis Doomadgee), a 36-year-old Aboriginal man, died from intra-abdominal haemorrhage due to liver rupture following an encounter with Senior Sergeant Christopher Hurley at Palm Island Police Station on 19 November 2004. Mulrunji was arrested for minor public order offences following a trivial incident. After being removed from the police vehicle, he struck Hurley, who responded with force. Both men fell through the station doorway. The Coroner found Hurley struck the supine Mulrunji multiple times, causing fatal compressive injuries to the upper abdomen. Critical clinical lessons include: arrest should be a last resort with alternatives preferred; health assessments must occur immediately upon custody despite initial non-cooperation; frequent, thorough cell checks are essential for intoxicated persons; no prisoner should be left unmonitored; CPR-trained staff and resuscitation equipment are mandatory; communication failures with Indigenous witnesses compromised the initial investigation.

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

Specialties

forensic medicineemergency medicinegeneral surgerytransplant medicine

Error types

diagnosticproceduralsystemdelay

Clinical conditions

liver ruptureportal vein ruptureintra-abdominal haemorrhagerib fracturesacute intoxicationblunt abdominal trauma

Contributing factors

  • inappropriate arrest for minor public order offence
  • failure to exercise police discretion appropriately
  • use of force by police officer against detainee in custody
  • no health assessment on reception into custody
  • failure to recognise serious internal injury
  • inadequate cell monitoring and checks
  • failure to perform cardiopulmonary resuscitation
  • significant intoxication affecting injury recognition
  • poor investigation of death in custody
  • compromised investigation integrity due to conflicts of interest
  • lack of cultural awareness and communication support

Coroner's recommendations

  1. Amend Police Powers and Responsibilities Act 2000 to reflect arrest as last resort with duty to consider alternatives
  2. Amend legislation to include explicit statutory duty to consider alternatives to detention of intoxicated persons in police cells
  3. Amend Operational Procedures Manual to instruct arrest as last resort and emphasise consideration of alternatives for intoxicated persons
  4. Police Commissioner to address training regarding legal bases for arrest without warrant and alternatives available
  5. Police Commissioner to provide training on RCIADIC recommendations relating to arrest of Aboriginal people for drunkenness and public order offences
  6. Establish specialised training for officers in Aboriginal communities prior to posting, including experiential training based on Kowanyama trial model
  7. Queensland Government to properly fund and support Community Justice Group on Palm Island
  8. Establish diversionary centre on Palm Island as alternative to police custody for intoxicated persons
  9. Establish community patrol on Palm Island with adequate funding and community consultation
  10. Amend OPM to fortify direction on thorough initial health assessment of all persons in custody; if initial assessment impeded by violence or non-cooperation, assessment must be conducted through alternative means or by another officer
  11. Urgently review OPM for greater practical guidance on health assessments of persons in custody
  12. Amend OPM to incorporate Medical Checklist used by Victorian Police; provide training and commence immediate use
  13. Police Commissioner to provide increased and improved training on health assessments, with intensive specialised training for watchhouse officers; include RCIADIC recommendations, general health status of Aboriginal populations, dangers of intoxication, and protocols for unconscious/semi-rousable persons
  14. Increase training for officers on monitoring equipment operation
  15. Make theoretical and practical training in first aid and resuscitation mandatory for all watchhouse officers; resource watchhouses with appropriate resuscitation equipment
  16. Conduct urgent review to ensure persons in custody are never left unmonitored and ensure adequate staffing levels
  17. Amend OPM to require investigation selection from region other than where death occurred
  18. Amend OPM to require Chief Commissioner or Deputy/Assistant Commissioner appointment of officer in charge of death in custody investigation
  19. Amend OPM to explicit requirement considering impartiality and appearance of impartiality when selecting investigation officers
  20. Amend OPM to explicitly require officers in death in custody investigations to disclose any relationship with officer involved or witness
  21. Establish clear protocols preventing investigated officer from meeting investigating officers at airport, driving them to scenes, or providing accommodation
  22. Amend OPM to more clearly state need for officers to consider impartiality and perception of impartiality throughout investigation
  23. Amend OPM to require officer in charge to instruct witnesses not to discuss matter prior to interview
  24. Police Commissioner to ensure officer training on OPM obligations in deaths in custody, with strict compliance with relevant sections and immediate family notification protocols
  25. Crime and Misconduct Commission to be actively involved in all deaths in custody investigations from outset; consider senior CMC officer involvement in all such investigations
  26. Police Commissioner to provide significant training on cross-cultural communication, support persons, and interpreters, particularly for officers working in large Indigenous communities
  27. Amend OPM to include Supreme Court of Queensland Equal Treatment Benchbook Chapter 9 on Indigenous Language and Communication as appendix; direct officers to follow and apply contents
Full text
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