Reconciliation and Social Justice Library

ROYAL COMMISSION INTO ABORIGINAL DEATHS IN CUSTODY

NATIONAL REPORT VOLUME 1

• NATIONAL REPORT VOLUME 1
  • PREFACE
  • ACKNOWLEDGEMENTS
  • ACRONYMS
  • THE FRAMEWORK OF THIS REPORT
  • CHAPTER 1 OVERVIEW
    • 1.1 THE ROYAL COMMISSION
    • 1.2 THE INDIVIDUAL DEATHS
      • THE OVER-ALL FINDINGS
      • HOW THE DEATHS OCCURRED
      • THE LIVES OF THOSE WHO DIED
    • 1.3 THE DISPROPORTIONATE NUMBERS OF ABORIGINAL PEOPLE IN CUSTODY
    • 1.4 THE IMPORTANCE OF HISTORY
    • 1.5 SOME CONSEQUENCES OF HISTORY
    • 1.6 REDUCING THE NUMBER OF ABORIGINAL PEOPLE IN CUSTODY--THE CRIMINAL JUSTICE SYSTEM
      • DIVERSION FROM CUSTODY
    • 1.7 REDUCING THE NUMBER OF ABORIGINAL PEOPLE IN CUSTODY THE FUNDAMENTAL QUESTION-EMPOWERMENT AND SELF-DETERMINATION
      • THE WILL TO RENEWAL AND TO SELF-DETERMINATION
      • THE ROLE OF THE BROADER SOCIETY
      • THE POLICY OF SELF-DETERMINATION
      • SELF-DETERMINATION AND NON-ABORIGINAL ATTITUDES
    • 1.8 THE IMPORTANCE OF THE ABORIGINAL ORGANISATIONS
    • 1.9 THE ELIMINATION OF DISADVANTAGE AND THE PROCESS OF RECONCILIATION
    • 1.10 AN OVERVIEW OF THE RECOMMENDATIONS
  • PART A: THE DEATHS INVESTIGATED BY THE ROYAL COMMISSION
    • CHAPTER 2 PROFILE OF THOSE WHO DIED
      • 2.1 INTRODUCTION
      • THE GEOGRAPHICAL DISTRIBUTION OF THE ABORIGINAL POPULATION
      • 2.2 DEMOGRAPHIC CHARACTERISTICS OF THE DECEASED
        • Age and Gender
        • Age and State
        • Place of Birth
        • Marital Status
        • Employment
        • Occupation
        • Highest Educational Level Attained
        • Community
        • Childhood Separation
      • 2.3 CRIMINAL HISTORY
        • REPORTED AGE AT FIRST CRIMINAL CHARGE
        • MOST FREQUENT OFFENCE DURING WHOLE OF LIFE
      • 2.4 REASON FOR LAST DETENTION
        • POLICE CUSTODY--REASON FOR NOT GRANTING BAIL
      • 2.5 CUSTODY
        • CUSTODIAL AUTHORITY
        • CUSTODIAL STATUS
        • DURATION OF CUSTODY PRIOR TO DEATH OR TRANSFER TO HOSPITAL OR OTHER MEDICAL FACILITY
      • 2.6 DETAILS OF THE DEATHS
        • Custodial Authority And Year Of Death
        • Place Of Death
        • Manner Of Death
        • Time Between When Last Seen Alive and Discovery of Death
      • 2.7 CONCLUSION
    • CHAPTER 3 THE FINDINGS OF THE COMMISSIONERS AS TO THE DEATHS
      • 3.1 THE INQUIRIES OF THE COMMISSIONERS
      • 3.2 THE FINDINGS AS TO THE IMMEDIATE CIRCUMSTANCES OF THE DEATHS
        • The Deaths By Hanging
        • Incidence of Death by Hanging
        • Distribution of Death by Hanging as Between Prison and Police Cells and as Between Regions
        • The Prison Hangings
        • The Police Cell Hangings
        • The Deaths By Trauma (Other Than Trauma Inflicted By Hanging)
        • The Types of Injuries that Caused Death
        • DEATHS DIRECTLY ASSOCIATED WITH HARMFUL USE OF ALCOHOL AND OTHER DRUGS
        • DEATHS FROM NATURAL CAUSES
        • DEATHS OCCURRING IN HOSPITAL
        • SUMMARY
      • 3.3 THE FINDINGS OF THE COMMISSIONERS AS TO THE CUSTODIAL CARE OF THOSE WHO DIED IN CUSTODY
        • INTRODUCTION
          • Duty of Care Towards Those in Custody
        • THE FINDINGS OF THE COMMISSIONERS AS TO THE CUSTODIAL CARE OF THOSE WHO DIED IN POLICE CUSTODY
          • System Weaknesses
          • Standing Orders;
          • Assessment of Prisoners on Reception:
          • Communication:
          • Regular Checking of Prisoners:
          • Checking on Observation of Orders and Procedures:
          • Architectural Deficiencies:
          • Individual Failure To Exercise Reasonable Care
          • The Queensland Community Lockup Deaths:
          • Resuscitation:
        • THE FINDINGS OF THE COMMISSIONERS AS TO THE CUSTODIAL CARE OF THOSE WHO DIED IN PRISON CUSTODY
          • INTRODUCTION
          • PRISON MEDICAL SERVICES
          • OTHER CRITICISMS OF CUSTODIAL CARE
          • Remand Prisoners:
        • THE FINDINGS OF THE COMMISSIONERS AS TO THE CUSTODIAL CARE OF THOSE WHO DIED IN JUVENILE DETENTION CENTRES
        • SOME OTHER OBSERVATIONS CONCERNING THE CUSTODIAL DEATHS
        • EMERGENCY RESPONSE TRAINING, INCLUDING RESUSCITATION
        • THE FINDINGS OF THE COMMISSIONERS AS TO MATTERS OF HOSPITAL TREATMENT
        • A CONCLUSION FROM THE FINDINGS AS TO CUSTODIAL CARE
      • 3.4 CREATING SUSPICIONS
      • 3.5 ABORIGINAL EXPECTATIONS ABOUT THE ACTIONS WHICH THE COMMISSION MIGHT TAKE
    • CHAPTER 4 THE ADEQUACY OF PREVIOUS INVESTIGATIONS
      • 4.1 INTRODUCTION
      • 4.2 POLICE INVESTIGATIONS
      • 4.3 DEPARTMENTAL INVESTIGATIONS
      • 4.4 AUTOPSIES (POST-MORTEM EXAMINATIONS)
      • 4.5 CORONIAL INQUIRIES
        • ADEQUACY OF CORONIAL INQUESTS REVIEWED BY THE COMMISSION
        • STATUS AND QUALIFICATIONS OF CORONERS
        • LEGISLATIVE AND PROCEDURAL STRUCTURES
          • Structure and Administration of Coronial Systems
        • CORONIAL JURISDICTION AND INQUESTS
          • Coroner's Investigative Powers
          • Coroner's Powers on Inquest
          • Lawyer to Assist a Coroner
          • Inquest Findings and Recommendations
      • 4.6 THE RIGHTS OF THE DECEASED'S FAMILY
        • INTRODUCTION
        • NOTIFICATION OF DEATH
          • Access to the Body of the Deceased
          • Access to the Place where Death Occurred
          • Right to Request or Refuse Autopsy
          • Right to an Independent Pathologist
          • Right to Notification of an Inquest
          • Right of Appearance at Inquest
          • Access to Documents
          • Right to Call Evidence and Make Submissions
          • Access to Legal Representation
          • Counselling Services
      • 4.7 CONCLUSION
  • PART B: THE DISPROPORTIONATE NUMBER OF ABORIGINAL PEOPLE IN CUSTODY
    • CHAPTER 5 THE DISPROPORTIONATE NUMBERS IN CUSTODY
    • CHAPTER 6 ABORIGINAL PEOPLE IN CUSTODY: SOME BASIC FACTS
      • 6.1 ABORIGINAL PEOPLE IN POLICE CUSTODY
        • INTRODUCTION
        • AGE OF POLICE CUSTODY DETAINEES
        • GENDER
      • 6.2 ABORIGINAL PEOPLE IN PRISON CUSTODY
        • AGE GROUP DISTRIBUTION
        • GENDER OF ABORIGINAL PRISONERS
    • CHAPTER 7 REASONS FOR CUSTODY
      • 7.1 POLICE CUSTODY
        • OFFENCES INVOLVED
        • PUBLIC DRUNKENNESS
      • 7.2 PRISON CUSTODY
        • OFFENCES INVOLVED
    • CHAPTER 8 DURATION OF CUSTODY
      • 8.1 POLICE CUSTODY
        • STATE-BY-STATE COMPARISONS
      • 8.2 PRISON CUSTODY
    • CHAPTER 9 THE EXTENT OF THE DISPROPORTION
      • 9.1 INTRODUCTION
      • 9.2 DISPROPORTIONATE NUMBERS IN POLICE CUSTODY
        • STATE-BY-STATE COMPARISONS
      • 9.3 DISPROPORTION IN PRISON POPULATIONS
      • 9.4 SUMMARY OF PART B