Coroner's Finding: HUNT Kunmanara

Contributing factors

• respiratory depression from petrol fumes
• possible asphyxia due to seal formed by petrol can over nose and mouth
• chronic petrol sniffing (10+ years)
• poverty and socio-economic disadvantage
• lack of employment and educational opportunities
• boredom and hopelessness
• inadequate intervention and rehabilitation services
• geographic isolation and limited access to health services
• pre-existing neurological damage from petrol sniffing
• malnutrition and poor health status

Coroner's recommendations

1. Commonwealth, State and Territory Governments should recognise petrol sniffing as an urgent threat to Anangu communities requiring coordinated response
2. Governments must address socio-economic factors including poverty, hunger, lack of education, unemployment, and hopelessness as underlying causes
3. Governments should recognise responsibility to assist Anangu rather than expecting communities to solve the problem alone
4. Commonwealth and State governments should accelerate efforts through CBRG and APLIICC, moving beyond information gathering phase
5. Establish inter-governmental coordination to avoid fragmentation of service delivery
6. Establish senior government presence in Alice Springs or on the Lands with local knowledge and authority to manage programs and engage with service providers
7. Implement multi-faceted strategies at primary, secondary, and tertiary intervention levels rather than isolated approaches
8. Implement the proposal for four youth workers and coordinator for the Lands immediately with attention to housing and employment conditions
9. Institute neuropsychological assessment programs to evaluate rehabilitation suitability and disability service needs
10. Establish culturally appropriate Homelands/Outstation programmes for respite, recreation, skills training, and education
11. Continue funding Avgas initiative through Comgas scheme as an interdiction strategy
12. Increase range of sentencing options available to courts through community service bonds, Outstations, and secure care facilities
13. Amend Public Intoxication Act to apply on the Lands with petrol declared as a drug, with associated secure care facility for sobering up
14. Explore possibility of night patrols in consultation with police as part of crime prevention strategy
15. Expand FAYS role from narrow child protection focus to broader proactive community development
16. Urgently upgrade disability services for petrol sniffing victims and implement Tregenza's recommendations
17. Commence planning for multi-functional secure care facilities accessible to all communities
18. Implement energetic, creative recruitment strategies for qualified staff using financial incentives and career development opportunities
19. Implement SAPOL Community Constable Scheme review recommendations including permanent sworn presence at Umuwa and consideration of Murpatja base
20. Ensure Marla Police Station reaches full staffing establishment and develop further recruitment measures
21. Implement all interventions as coordinated multi-faceted strategy rather than piecemeal
22. Re-examine Royal Commission into Aboriginal Deaths in Custody recommendations to assess implementation gaps