Coroner's Finding: KEN Kunmanara (2)

Contributing factors

• chronic petrol sniffing (10+ years)
• respiratory depression from petrol fumes
• asphyxia from seal created by tin over face
• chronic poverty and unemployment
• lack of education and employment opportunities
• family violence and domestic violence
• social alienation and hopelessness
• inadequate government intervention programs
• lack of rehabilitation facilities
• insufficient police presence and community support services
• absence of detoxification/secure care facilities

Coroner's recommendations

1. Commonwealth, State and Territory Governments recognise petrol sniffing as an urgent threat to Anangu communities requiring whole-of-government response
2. Address socio-economic factors including poverty, hunger, illness, lack of education, unemployment, boredom and hopelessness
3. Recognise wider Australian community responsibility to assist Anangu with this problem which has no precedent in traditional culture
4. Commonwealth and SA Governments accelerate efforts through Central Australian Cross Border Reference Group and APLIICC to move beyond information gathering phase
5. Prioritise inter-governmental coordination to avoid fragmentation of service delivery
6. Establish senior government presence in region, preferably on Anangu Pitjantjatjara Lands, to develop local knowledge and relationships rather than relying on infrequent meetings
7. Implement multi-faceted strategies at primary, secondary and tertiary intervention levels
8. Appoint four youth workers and coordinator for Anangu Pitjantjatjara Lands forthwith with proper employment, housing and support conditions
9. Institute programme of neurological and neuropsychological research and evaluation of petrol sniffers to assess rehabilitation suitability and disability service needs
10. Establish culturally appropriate Homelands/Outstations for community respite, recreation, skills training and education
11. Continue funding Avgas initiative through Comgas scheme as successful interdiction strategy
12. Increase range of sentencing options available to courts, including enforcement of community service orders through Department for Correctional Services supervisors
13. Amend Public Intoxication Act to apply on Anangu Pitjantjatjara Lands with declaration that petrol/hydrocarbons are drugs under the Act
14. Explore possibility of encouraging and supporting community-established night patrols as part of overall crime prevention strategy in consultation with police
15. Consider expanding FAYS role into more proactive community development
16. Urgently upgrade disability services for victims of petrol sniffing and implement Tregenza review recommendations
17. Commence immediate planning for establishment of secure care facilities accessible from all Anangu Pitjantjatjara Lands communities with multi-functional role for detention, detoxification, treatment and rehabilitation
18. Undertake energetic, concerted and creative recruitment approach for qualified staff with special measures addressing isolation, cultural deprivation and family employment needs
19. Implement SAPOL review recommendations concerning permanent sworn SAPOL presence on Anangu Pitjantjatjara Lands, establish officers at Umuwa and reconsider Murpatja base
20. Ensure SAPOL Marla station achieves full staff establishment to provide effective policing service
21. Implement recommendations as integrated multi-faceted strategy rather than piecemeal
22. Re-examine Royal Commission into Aboriginal Deaths in Custody recommendations to assess degree of implementation