Latest news with #CoronialInquest
ABC News
10-07-2025
- ABC News
Coroner finds Indigenous man 'slipped or fell' into Narrabri Creek
A coronial inquest into the death of a First Nations man in northern NSW in 2021 has found he was likely drug-affected when he "slipped or fell" into a creek and drowned. WARNING: Aboriginal and Torres Strait Islander readers are advised this story contains the name and image of a man who has died. They are used with the permission of his family. Nathan Markl, 31, was last seen alive on July 7, 2021, when he dropped a friend home in Narrabri. More than two weeks later his body was found in Narrabri Creek. In handing down her findings on Thursday, Deputy State Coroner Carmel Forbes said she was satisfied the Gomeroi man died by misadventure. "[Mr Markl] likely exited the car and entered the water, at or about 9:17pm, on the seventh of July," she said. "I am satisfied Mr Markl either slipped or fell into the Narrabri Creek and died. The inquest heard a police diving squad found Mr Markl's body 11 kilometres downstream from his vehicle July 23. Magistrate Forbes said wet weather at the time may have been a factor in his death. Police said his death was not suspicious. An autopsy was unable to establish the cause of death but found Mr Markl had no injuries. Leah Joy Murray, the pathologist who conducted the autopsy, told the inquest that the length of time Mr Markl's body was submerged in water made it difficult to determine the cause of his death. "The water clouds the ability to see bruises, scrapes and abrasions," she said. Dr Murray said there were no signs of fractures or disease that would have contributed to Mr Markl's death. "Anti-psychotic medication was found [in his system], as well as meth and alcohol," she said. The inquest heard Mr Markl had a cognitive impairment and struggled with substance abuse and mental health issues. "It's likely Mr Markl was abusing methamphetamine and cannabis," counsel assisting the coroner Ben Fogarty told the inquest. Witnesses told the inquest Mr Markl was heavily affected by drugs in the lead-up to his death. "He was on edge and I was wary of him," a witness said. During the two-day inquest in June the court heard Mr Markl was a father who loved his five children. The Gomeroi man was described as a "character" who had a special relationship with his mother, Jo Harradine. Ms Harradine told the inquest that her she feared her son would fall in with the wrong crowd due to his cognitive impairment. "It was hard for me as a mother," she said. Ms Harradine previously told the ABC she had long questioned the circumstances that led to Mr Markl's death. This week marks four years since her son went missing. The Gomeroi, Ngarrindjeri and Dunghutti woman declined to comment on the findings, but did say was not "likely to be the outcome I wanted".
ABC News
05-07-2025
- ABC News
Almost six years after the police shooting of Kumanjayi Walker tore the Northern Territory apart, the coroner will hand down her findings
WARNING: Aboriginal and Torres Strait Islander readers are advised that this article contains the name and image of an Indigenous person who has died, used with the permission of their family. This story contains racist and offensive language and images, as well as references to sexual assault. On the dusty Tanami Road to Yuendumu, the community's message is scrawled on the back of road signs. The graffitied words "no guns in Yuendumu" and "Justice For Walker" are slightly faded now. After all, it's been almost six years since Kumanjayi Walker died in the Indigenous community at the end of the road. "We were all terrified, we were scared, we didn't know what to do," says senior Warlpiri elder, Ned Jampijinpa Hargraves. The tragedy of November 9, 2019 is as raw today as it was then. But there's hope that tomorrow, the coroner's long awaited inquest findings will answer questions that have been asked since that night. Coronial inquests are not bound by the same strict rules of evidence which apply to criminal cases; meaning for almost three years, NT Coroner Elisabeth Armitage was able to explore issues well beyond the night Mr Walker was killed. Ultimately, she sought to understand how and why the 19-year-old man and constable ended up in a dark room in House 511 in Yuendumu in the first place. She described some of what she uncovered as "deeply disturbing", after unveiling allegations of widespread racism within even the highest ranks of the police force, and reviewing body worn footage of violent arrests. At the beginning of the inquest, the man who fired the fatal shots, former constable Zachary Rolfe says he was painted as a "racist, violent cop". By the time he gave evidence more than a year later, the coroner had heard enough to suggest Zachary Rolfe himself was not the problem. "There was an assumption that [Mr Rolfe] was a rotten apple, that he was an exception to the otherwise very harmonious and well-intentioned NT Police force that was not racist," law professor Thalia Anthony says. Text messages downloaded from Mr Rolfe's phone showed even senior police regularly used derogatory terms including "coons" and "neanderthals". Such language was "normalised" at the station, Mr Rolfe told the coroner. He revealed a series of racist mock awards were handed out at Christmas parties by the force's most elite tactical unit and, while his motivations for doing so were questioned, Mr Rolfe himself uncovered some of the most explosive evidence the inquiry heard. "Racism killed Kumanjayi," Mr Walker's cousin, Samara Fernandez-Brown said. The coroner heard conflicting evidence about the instructions given to Mr Rolfe and his colleagues on the night of the shooting. The local sergeant said she had a plan to effect a safe arrest of Mr Walker — who was wanted for allegedly breaching a court order and threatening police with an axe — on Saturday, November 10 at 5am. Ideally, the officers would be joined by a local Aboriginal cop who knew him and would able to put cuffs on the 19-year-old before he'd properly woken up. But Zachary Rolfe and his specialist Immediate Response Team (IRT) colleagues said they had driven in on the afternoon of November 9 — long-arm weapons and police dog in tow — under the impression they were to arrest Mr Walker and take him back to Alice Springs. They left the police station at dusk and found their target at House 511. As the sun set, Mr Walker was suddenly face-to-face with two police officers in his mother's living room. He stabbed Constable Rolfe in the shoulder with a pair of scissors. The officer responded by firing his Glock three times. Yuendumu's nurses had evacuated for the weekend hours earlier, after a string of break-ins at their homes. So Kumanjayi was taken to the police station, where officers did what they could to treat three close-range gunshot wounds. As the 19-year-old lay dying on the floor of a police cell, his family sat outside in the dark — literally and figuratively. They learned the next day that the plane they saw come in that night was not in fact taking their loved one to hospital. Because he had died just hours after the shooting. Coronial findings are not legally binding, meaning the coroner's recommendations could simply be left to gather dust at Parliament House. But the chief minister says her government will be "upfront" with the community about which ones it accepts, and which it will not. She cannot convict any person of a criminal offence and Zachary Rolfe has already been acquitted of all charges related to the shooting, so he cannot be charged again. But the coroner can refer unnamed individuals to prosecutors, and make widespread recommendations for systemic change within government departments; in this case likely targeted at health, education, corrections, police and housing. The inquest itself has already led to changes across various government departments — particularly the Northern Territory Police Force. Zachary Rolfe is no longer a serving officer, dismissed after penning an open letter criticising the coroner, police commissioner and inquest process. The force itself has lost two commissioners since the inquest began. A new executive role, designed to identify and combat racism within the ranks has been created and a string of changes to training have been rolled out. "Police have been working towards probably a lot of what [the coroner's] recommendations will set out and recommend," Acting NT Police Commissioner Martin Dole said. "But we'll consider those when they're handed down." Regardless of what Coroner Elisabeth Armitage ultimately finds, her report will be another in the long list of recommendations made to avoid deaths such as Kumanjayi's since the 1991 Royal Commission into Aboriginal Deaths in Custody. Recommendations made before Kumanjayi Walker was even born. "The inquest into his death has been gruelling, shocking and devastating," Ms Fernandez-Brown said. What was initially scheduled to be a three-month inquiry has taken almost three years to complete. With the coroner's broad scope of inquiry, came a string of legal appeals — led predominantly by Mr Rolfe — arguing many of the issues she explored were irrelevant. He also urged the coroner to stand aside from the investigation, claiming she was biased, leading to further delays in the hearings. "I think it's gone on for too long and I think things should have been pulled in," Professor Anthony says. "I think the coroner should have been more assertive in terms of how she dealt with a lot of the evidence and the witnesses." Elisabeth Armitage has long been clear that her inquest was never just about Zachary Rolfe and Kumanjayi Walker, but the systems which put them on the same fatal collision course in the first place. As she examined Mr Rolfe's previous career as a soldier and breaches of rules and regulations, she heard evidence about Mr Walker's long list of interactions with the justice system. She took in details about police recruitment processes and mental health support, while hearing it was likely Mr Walker was born with fetal alcohol spectrum disorder. Her report was due to be handed down last month, but just days beforehand, another young Warlpiri man, Kumanjayi White, lost his life in police custody. The Yuendumu community was thrown right back to the start of another healing process, as this one was finally within arm's reach. Elisabeth Armitage has had a tough job in front of her from the beginning. There is not a corner of the Northern Territory untouched by the ripple effect of Kumanjayi Walker's death. Delivering a report which brings closure to all involved, is an impossible task. The shooting tore apart sections of the NT Police Force — many officers are vehemently defensive of their colleague, who was charged with the most serious offence in the criminal code just four days after firing his Glock on the job. It's the stuff of nightmares, for men and women in uniform. They feel Zachary Rolfe has been unfairly targeted and that his charging was politically motivated, to appease Indigenous communities. His text messages, personal health records and details of past romantic relationships are now in the public realm. Irrelevant information, they argue, when it comes to the coroner determining the cause and circumstances of a death in custody. On the other side of the divide are a grieving family and their supporters, upset and confused by the loss not only of a young Warlpiri-Luritja man, but also of any trust they had in the justice system. Zachary Rolfe's unequivocal acquittal at the Supreme Court, by a jury lacking any Yapa faces, dealt his family another blow. Accountability and justice, in their view, was not found in the criminal Kardiya courts. They hold onto hope that their years of travelling hundreds of kilometres from the bush to the coroner's court to share their truths will lead to better outcomes for the current generation of Warlpiri youngsters growing up in the desert community. After losing two grandsons in police custody, Mr Jampijinpa Hargraves wants to see unity on his country. "We should be … together," he said. But 19-year-old Kumanjayi Walker can't be brought home again. Regardless of the coroner's findings, there will be no winners in the pages of her report.
The Guardian
09-06-2025
- Health
- The Guardian
We asked every Australian state why ligature points in jails had not been removed. Here are their responses
Guardian Australia has this week published an investigative series revealing the shocking death toll from inaction on known hanging points in Australian prisons. The investigation found that 57 deaths have occurred using ligature points that were known to authorities but not removed, often despite stark warnings about the dangers they posed. In one case, the same hanging point was used in a Queensland prison in 10 hanging deaths across almost two decades, despite repeated calls for it to be addressed. Each state was asked why the hanging points were not removed and what it was doing to make prisons safe. Here are the responses in full: Queensland Corrective Services takes the safety and wellbeing of prisoners in custody very seriously and all deaths in custody are subject to police investigation and Coronial inquest. Several protective measures are in place to prevent prisoners from harming themselves, including comprehensive suicide risk assessment and management plans which inform where prisoners are accommodated. All frontline QCS officers undertake mandatory training in suicide prevention and QCS' Mental Health Strategy 2022-2027 is identifying people in custody or supervision with mental ill health and assessing them early, to provide them with the supports and services needed including necessary supervision, monitoring and access to medical, psychologist, and other relevant supports. In addition, QCS is always working to ensure the infrastructure in each correctional facility minimises risks for self-harm or suicide. In Queensland, 92.9% of all secure cells have a safer cell design and prisoners identified as being at risk of self-harm are placed in the most appropriate accommodation to keep them safe. This equates to 7,550 (95.7%) built beds within secure safer cells. When the new Lockyer Valley Correctional Centre comes on-line, 93.5% of Queensland secure cells will be safer cell design compliant. This will equate to 96.2% built beds within secure safer cells. Corrective Services NSW is committed to reducing all preventable deaths in custody and continually seeks to improve the design and safety of correctional centres. The NSW Government has invested $16 million to make our prisons safer by removing ligature points. This will continue the extensive work that has already been undertaken across several facilities as part of our coordinated statewide infrastructure program to refurbish cells and remove obvious ligature points or cell furniture that could pose a self-harm risk. This has included the removal of ligature points from almost 800 cells, as well as replacing cell doors, grills, beds, basins and tapware. An additional 145 cells are expected to be completed by July 2025. In addition to ligature removal and refurbishments, Corrective Services NSW has well-established policies and procedures for the care and management of inmates identified as being at risk of self-harm or suicide. The Department of Justice has been undertaking a comprehensive program of ligature minimisation in the State's prisons since 2005, noting that it is not possible to achieve the complete elimination of all ligature points. The program to increase the number of fully ligature-minimised cells across the custodial estate is ongoing, with priority given to facilities with the highest risk and need. This work is also complemented by suicide prevention programs and risk minimisation strategies. The Department is expanding the range of services provided to meet the needs of an increased prisoner population, including those with complex mental health issues. Sign up for Guardian Australia's breaking news email This includes the Casuarina Prison Stage 2 Expansion Project which will deliver critical new infrastructure to meet future demands of high-needs or at-risk prisoners and will house 36 special purpose beds in a Mental Health Support Unit with dedicated therapeutic accommodation for prisoners with psychiatric conditions. The Department also established the Clinical Workforce Committee to develop strategies to retain specialist health and mental health staff in Corrective services. The Department is continuously strengthening protocols for managing recommendations made by oversight bodies, including the Coroners Court of Western Australia. The Department is committed to addressing all supported Coronial recommendations and considers all recommendations on a case-by-case basis. If there are practical barriers to implementing proposed recommendations, the Department works with the Coroners Court to develop alternative strategies to achieve practical outcomes that address the intent of the original recommendation. Every death in custody is a tragedy for the person's family, friends and community. It is also extremely distressing for DCS staff and first responders. DCS recognises the importance of reducing risks associated with prisoner self-harm and suicide and is committed to enhancing safe accommodation at all sites. The Department has acted on Coronial recommendations to remove hanging points and over the last decade has invested about $200 million in new infrastructure and upgrades to existing infrastructure to ensure safe cell design in prisons across the state. Sign up to Breaking News Australia Get the most important news as it breaks after newsletter promotion New builds at the Adelaide Women's Prison and Yatala Labour Prison which are currently underway also adhere to the safe cell standard. Upgrades to aging infrastructure and cells at various sites continue to be undertaken. A range of programs have also been implemented to identify those prisoners who are at most risk, which includes targeted culturally appropriate services for Aboriginal prisoners. The Tasmania Prison Service (TPS) has adopted a risk-based approach which has resulted in the removal of many hanging points across prisons. All new builds in the TPS comply with prison infrastructure standards and are constructed to ensure no hanging points exist. All cells for managing maximum-security prisoners and those considered to be at risk of SASH are constructed to ensure that no hanging points exist. The TPS takes an individualised approach to SASH risk and the safety of prisoners at risk of SASH is driven by structured professional judgment incorporating individual assessments, which takes into account evidence-based practice, research, and a personal assessment of the individual from a multi-disciplinary approach. Prisoners who are considered at risk of SASH following assessment are housed in units of the prison where the risk of self-harm is mitigated through various measures including decisions to limit a prisoner's movements or limit their access to clothing items, footwear, cutlery, linen or other items that may be used to cause harm. This approach is consistent with various human rights principles including treating each prisoner as an individual, minimising differences between prison life and liberty and not assuming that all prisoners are at risk of SASH. Prisoners at risk of SASH are provided mental health supports and regular interventions. We know that people coming into custody can have complex mental health issues. We take these risks very seriously and ensure prisoners are provided with the support they need and are housed in appropriate accommodation. We have strong measures in place to reduce self-harm and suicide, including specialist mental health services and clinicians on-site in prisons. Staff are also trained to identify at-risk people and make referrals. The Victorian Government continues to invest in modern prison facilities to improve the rehabilitation and safety of people in custody, such as the new Western Plains Correctional Centre opening in July. The ACT Government is committed to continuous improvement to minimise harm in our correctional facilities. ACT Corrective Services has rigorous processes in place to ensure it maintains the highest standards of care for all people in custody. The Alexander Maconochie Centre (AMC) has a Facilities Management team, which consists of highly experienced trade professionals who are well-versed in working with Custodial Operations to identify and address obvious ligature risks as part of routine maintenance and repair activities. Where ligature risks are identified, further assessments are conducted to determine remedial action required to suitably address the risk. Work required is predominantly managed by this team and frequently funded through existing operational expenditure allocations. It is therefore difficult to determine how much has been spent on ligature point prevention and remediation. However, where ligature risks have been addressed as part of a defined project, the associated costs/funding are included below. ACT Corrective Services had been provided separate reports by the ACT Coroners Court and ACT Inspector for Custodial Services into Mr Rich's death. These reports provided important insights to help prevent harmful and tragic outcomes from being repeated. Significant work has been undertaken to address the risks identified in the reports, including: upgrades to the Management Unit's rear cell doors, which were completed in May-June 2022 and cost approximately $3,500-$4,500. the commissioning of a further review into the Management Unit's rear cell doors, which is currently underway. As outlined in the ACT Government's Response to the Coroner's report, ACTCS is committed to publishing the findings to the greatest extent possible once the review is complete. release of an updated Intervention Hoffman Knife Operating Procedure, which became effective in November 2023 and states Hoffman knives are now personally issued to correctional officers. development of an ACT Corrective Services Suicide Prevention Framework, which was released in April 2025 and guides how ACT Corrective Services staff work with clients, both in the custodial and community correctional environments, to reduce suicide and suicidal behaviours, Other work to reduce cell ligature points that has been carried out or is being planned includes, but is not limited to: upgrades to cell furniture in the Management Unit, with $3,270 spent to repair identified ligature point risks. upgrades to cell furniture across various accommodation units, including to reduce potential ligature risks. This work is scheduled to be completed by May 2026, with a total estimated project cost of $174,440. Following recommendations from the NT Coroner in 2017, works to mitigate the risk of similar incidents by removing the ceiling fans [at Darwin Correctional Centre] was completed in September 2020.
RNZ News
05-06-2025
- RNZ News
Police believed LynnMall terrorist Ahamed Samsudeen could attack 'with little to no warning'
Ahamed Samsudeen took a knife from a supermarket shelf and stabbed six people. Photo: Supplied Police believed terrorist Ahamed Samsudeen could carry out an attack "with little to no warning" at least a month before he attacked shoppers at an Auckland supermarket. A coronial inquest into Samsudeen's death continues today, after he was shot by police during a knife attack at Countdown LynnMall on 3 September, 2021. The coroner's counsel Anna Adams read the results of a threat assessment of Samsudeen from 5 August, 2021. "Based on current information available regarding intent and capability Samsudeen is assessed to pose a high threat for a lone actor ideologically motivated attack," she read. "And based on current information if an attack was to occur it would be of low sophistication, e.g use of a knife or a vehicle, and could occur with little to no warning." The coronial inquest continued to examine Samsudeen's criminal history. Samsudeen spent almost four years remanded in prison after police found weapons and objectionable material at his home in 2018. Providing evidence on behalf of police, Detective Senior Sergeant Jason McIntosh read the charges Samsudeen faced during that time. "Samsudeen [was] charged with the offences including possession of offensive weapons: a hunting knife and throwing star... And the possession of objectionable publications, [including] an islamic state video on how to kill non-muslims in which a masked man cuts the throat and wrists of a restrained prisoner," he recounted. By the time Samsudeen was sentenced in 2021, he had spent so much time in prison that authorities had no choice but to release him. Anna Adams summarised the High Court's decision. "The High Court concluded that because Mr Samsudeen had spent so much time in prison already he had to be credited that as time served and therefore the only option was to release him on supervision," she explained. She turned to McIntosh for clarification. "In terms of the position that police were in as of July 2021, is it a fair characterisation that the police were dealing with a person in the community who law enforcement were very concerned about but fundamentally was free to be in the community on supervision?" She asked. "Yes," he replied. The inquest continues with a forensic analysis of footage captured during the attack, including security footage. Sign up for Ngā Pitopito Kōrero , a daily newsletter curated by our editors and delivered straight to your inbox every weekday.
SBS Australia
07-05-2025
- SBS Australia
Westfield failures in the spotlight at Bondi stabbing inquest
Westfield failures in the spotlight at Bondi stabbing inquest Published 7 May 2025, 7:28 am A coronial inquest into last year's mass stabbing attack at Sydney's Bondi Junction Westfield has heard from the chief warden in charge of the emergency response on the day. The court heard about a series of security and management failures, including slow communication between staff, a delay in making public announcements and confusion over which messages should be relayed.
