Coroner's Finding: Ward Kunmanara

Contributing factors

• Petrol sniffing and intoxication (Ward, Ken, Cooper)
• Severe organic brain damage from chronic petrol sniffing with mental age of 3 years and epilepsy (Ken)
• Depression and substance abuse with rapid relapse pattern (Ryan)
• Inadequate emergency search procedures and delayed police response (Ken)
• Inadequate discharge planning after psychiatric hospitalisation (Cooper)
• Lack of qualified interpreters for Aboriginal patients
• Lack of culturally appropriate transport arrangements post-discharge (Cooper)
• Loss of family support and isolation (Ryan)
• Inadequate disability support and respite services
• Lack of coordination between correctional and mental health services

Coroner's recommendations

1. Commonwealth, State and Territory Governments recognise that petrol sniffing poses an urgent threat to the very substance of the Anangu communities
2. Socio-economic factors such as poverty, hunger, illness, lack of education, unemployment, boredom and feelings of hopelessness must be addressed
3. The wider Australian community should assist Anangu to address the problem of petrol sniffing, which is not solely Anangu responsibility
4. Accelerate efforts through Central Australian Cross Border Reference Group and Aboriginal Lands Task Force beyond information gathering phase
5. Prioritise inter-governmental coordination of approach to avoid fragmentation of effort
6. Establish senior official presence in region with local knowledge and cross-cultural expertise
7. Apply multi-faceted strategy including primary, secondary and tertiary interventions
8. All SAPOL personnel in rural and remote areas should receive search and rescue training
9. Address paucity of Anangu interpreters and improve liaison with community members on behalf of detained persons
10. Accelerate development of culturally appropriate correctional facility on or near the Anangu Pitjantjatjara Lands
11. Persist in efforts to develop appropriate secure care facility
12. Establish properly structured, funded and coordinated youth worker program
13. Extend neuropsychological testing of chronic petrol sniffers throughout the lands
14. Further support outstations/homelands projects
15. Continue support for Opal Unleaded fuel and develop security measures for Avgas
16. Review new correctional services model and consider further steps needed
17. Encourage and develop night patrols
18. Enhance role of Children, Youth and Family Services Unit in relation to children at risk
19. Ensure Coordinator of Services resides on the Anangu Pitjantjatjara Lands
20. Further develop crime prevention strategies once SAPOL fully established
21. Closely monitor adequacy of disability services program and urgently address shortfalls
22. SAPOL should persist with efforts to provide personnel and accommodation on the lands
23. Implement interventions as part of overall multi-faceted strategy not piecemeal
24. Re-examine Royal Commission into Aboriginal Deaths in Custody recommendations