Coroner's Finding: Ryan Kunmanara

Contributing factors

• Petrol sniffing and intoxication
• Organic brain damage from chronic substance abuse
• Severe intellectual disability requiring 24-hour care
• Inadequate disability services and respite care
• Delayed police search and rescue response
• Failure to treat missing person as emergency
• Inadequate discharge planning from psychiatric detention
• Lack of coordination between correctional and mental health services
• Lack of qualified interpreters for Aboriginal languages
• Inadequate support for transport and accommodation post-release
• Mental illness with substance abuse
• Social isolation and lack of community supports
• Chronic substance abuse including cannabis and marijuana

Coroner's recommendations

1. Commonwealth, State and Territory Governments should recognise petrol sniffing as urgent threat requiring coordinated response
2. Address socio-economic factors (poverty, hunger, illness, lack of education, unemployment, boredom, hopelessness)
3. Recognise wider Australian community responsibility rather than expecting Anangu to solve alone
4. Accelerate Commonwealth and State Government efforts beyond information-gathering phase
5. Prioritise inter-governmental coordination to avoid fragmentation of service delivery
6. Establish presence of senior trusted officials in region with authority to manage programs
7. Implement multi-faceted strategies aimed at primary, secondary and tertiary intervention levels
8. Ensure all SAPOL personnel in rural/remote areas receive adequate training in search and rescue operations
9. Address paucity of Aboriginal interpreters and improve liaison for detainees
10. Accelerate development of culturally appropriate correctional facility on or near Anangu Pitjantjatjara Lands
11. Persist in establishing appropriate secure care facility (distinct from correctional)
12. Establish properly structured, funded and coordinated youth worker program
13. Extend neuropsychological testing throughout Anangu Pitjantjatjara Lands for chronic petrol sniffers
14. Further support outstations/homelands projects
15. Commonwealth to continue supporting Opal Unleaded fuel and security measures
16. Review Department for Correctional Services new service model and further improve
17. Further encourage and develop night patrols
18. Enhance Children, Youth and Family Services role in addressing underlying circumstances
19. Ensure Coordinator of Services resides on Anangu Pitjantjatjara Lands
20. Further develop SAPOL crime prevention strategies
21. Closely monitor disability services program adequacy
22. SAPOL to persist with personnel and accommodation provision and safety strategies
23. Implement interventions as multi-faceted strategy not piecemeal
24. Re-examine Royal Commission into Aboriginal Deaths in Custody recommendations