Coroner's Finding: Ward Kunmanara

Contributing factors

• chronic petrol sniffing causing organic brain damage and epilepsy
• inadequate disability services and respite care
• mental health issues including depression and substance abuse
• inadequate search and rescue response
• extreme heat exposure
• isolation and poor social supports
• lack of correctional facility on lands requiring imprisonment away from community
• inadequate transition planning on release from secure psychiatric facility

Coroner's recommendations

1. Commonwealth, State and Territory Governments should recognise petrol sniffing poses urgent threat to Anangu communities
2. Address socio-economic factors including poverty, hunger, illness, lack of education, unemployment and hopelessness
3. Governments should not assume solutions must come from Anangu alone but should provide external expertise and support
4. Commonwealth and South Australian Governments should accelerate efforts beyond information gathering phase through Central Australian Cross Border Reference Group and Aboriginal Lands Task Force
5. Prioritise inter-governmental coordination of approach
6. Establish senior government officials on Anangu Pitjantjatjara Lands with authority and local knowledge for ongoing program management
7. Continue implementing multi-faceted intervention strategies at primary, secondary and tertiary levels
8. Commissioner of Police should ensure all SAPOL personnel in rural and remote areas receive search and rescue training emphasising timely and adequate response protocols
9. South Australian Government should address paucity of Anangu interpreters and improve liaison for detained persons
10. Premier should urgently consult on development of culturally appropriate correctional facility on or near the Lands or at proximate tri-state location
11. Aboriginal Lands Task Force should persist with outstanding issues to develop appropriate secure care facility at earliest opportunity
12. Department for Families and Communities should establish properly structured, funded and coordinated youth worker program following review
13. Disability Services Office and Department for Families and Communities should extend neuropsychological testing throughout the Lands
14. Support further establishment of outstations/homelands projects
15. Commonwealth Government should continue supporting Opal Unleaded fuel availability and develop security measures
16. Department for Correctional Services should consider further steps following review of service model
17. Further encourage development of night patrols
18. Department of Families and Communities should enhance Children, Youth and Family Services role in addressing at-risk children
19. Department of Health and Department for Families and Communities should ensure Coordinator of Government Services resides on the Lands
20. SAPOL should further develop crime prevention strategies once fully established on Lands
21. Disability Services Office should closely monitor adequacy of programs and urgently address shortfalls
22. SAPOL should persist with personnel and accommodation provision and develop safe community strategies
23. Implement interventions as coordinated multi-faceted strategy not piecemeal
24. Commonwealth and State Governments should re-examine Royal Commission into Aboriginal Deaths in Custody recommendations for implementation