Colin Barnett

Two months after the death of a 22-year-old Aboriginal woman in police custody, Western Australian Premier Colin Barnett made a promise to her mother.

Speaking at a national day of action following the tragic death of Ms Dhu, whose full name isn’t used for cultural reasons, Barnett made a “personal commitment” to work to prevent indigenous deaths in custody and reduce incarceration rates.

“I will do that,” Barnett told the protesters. “You then judge me on whether I succeed or not, but I give you that commitment today. I promise you, whatever the truth is we will find it, and I am very sorry for your loss.”

Now, more than two years later, a coroner’s report has presented the Premier yet another opportunity to make good on this promise and begin implementing recommendations that were first suggested more than 25 years ago following the Royal Commission Into Aboriginal Deaths in Custody recommendations in 1991.

The story is well known now. On the 2nd of August 2014, the Yamatji woman was taken into police custody in South Hedland for unpaid fines. Over the next two days, she would twice be taken to the nearby Hedland Health campus after complaining of pain from a fractured rib suffered months earlier in a domestic violence incident, and twice be ruled fit for custody and returned to the police station.

The third time Dhu was taken to the medical centre, she would not return. The coroner’s report says she died of “staphylococcal septicaemia, and pneumonia”, which started from an infection from the fractured rib.

Two and a half year’s following Dhu’s death, a coroner’s report has found that the police officers involved acted in an “inhumane and unprofessional” manner, and that her death was entirely avoidable.

The Human Rights Law Centre worked closed with the Aboriginal Legal Service and Dhu’s family in providing legal support, and director of legal advocacy Ruth Barson says the coroner’s report can only go so far in providing closure and accountability for the family.

“What’s really important to remember is that justice can never really be done,” Barson told Crikey. “There’ll always be a grieving family and a grieving community.”

But the report, handed down by coroner Ros Fogliani on Friday, includes a number of recommendations that fall largely in line with those of the royal commission. But it is the the harrowing account of Dhu’s final days, and the “profoundly disturbing” CCTV footage released to the public, that may finally spur the government into action.

The coroner’s inquest began in November last year and last four weeks. The final report, 165 pages long, details Dhu’s final days in excruciating detail, the “inhumane” treatment of police officers and dismissive diagnoses from health professionals.

After being arrested for $3662.34 in unpaid fines, Dhu was ordered to spend four days at the South Hedland police lockup. She immediately began complaining of pain and begged for medical attention. On the night of August 2, 2014, Dhu was taken to Hedland Health campus but ruled fit for custody by the practitioner. The next afternoon she was again taken the same facility and, despite basic checks like temperature measurement not being completed, was returned to custody again.

The coroner’s report provides a damning account of the treatment of Dhu during this time, with the vast majority of officers believing her to be a “junkie” and “feigning” her illness.

By her third day in custody, Dhu could no longer feel her legs and was vomiting into a cup. She tried standing twice but fell onto her head. Her mouth had also become numb. Around midday the police officers finally decided to take her to hospital again, and handcuffed Dhu before dragging her, limp, by her arms into a police van. One officer lost grip and let Dhu fall onto her head again.

By this point Dhu was “clearly completely incapacitated” and unconscious in a wheelchair. When the attending medical staff realised the gravity of the situation they began resuscitation attempts but with no success.

Even up until this point, the police officers involved showed no sign of urgency, the coroner’s report found.

At 1.39pm on August 4, 2014, Dhu was pronounced dead.

“The events at the lock-up on 4 August 2014 will serve as a constant reminder of the dangers of failing to acknowledge the inherent right of every person in detention to be afforded human and dignified treatment,” the coroner’s report reads.

“In her final hours she was unable to have the comfort of the presence of her loved ones, and was in the care of a number of police officers who disregarded her welfare and her right to human and dignified treatment.”

The death “unleashed a wave of grief that has reverberated throughout the Aboriginal communities” and “traumatised” Dhu’s family, and one that has once again shone a spotlight on Western Australia’s incarceration rates of indigenous Australians.

While the account is powerful and damning, the recommendations included by the coroner largely reflect the royal commission’s recommendations years ago, including improved cultural awareness training for police, the presence of a lock-up keeper, and the introduction of a Custody Notification Service in line with that operating successfully in New South Wales.

The coroner also recommended that fine defaulters no longer be imprisoned in Western Australia.

“A lot of the recommendations mirror those in the royal commission’s recommendations,” Barson said.

“That speaks to the fact that the Western Australian government, 25 years later, is still needing to be told that those recommendations have currency and are critically important.”

While the recommendations made are important, Barson says there are some “critical things” missing, including a review of the police disciplinary procedures that took place following Dhu’s death.

Many have also criticised the report for doing little to address the systemic racism and domestic violence that contributed to Dhu’s death, but Barson says this pervades the entire verdict.

“She didn’t use the word racism but did speak a lot to the prejudice and undertones in all of society,” she said. “Dhu’s death is really emblematic of prejudice being system-wide, not just located within the police or justice system but in the health system too.

“She did comment that for prejudice to be addressed there needs to be a society-wide, seismic shift. That’s really appropriate because it didn’t at all suggest that the prejudice we’re speaking about is something that can be shifted by one coroner’s recommendations.

“It is deeply rooted and will require a deep level of whole-of-government and community response.”

The coroner also did not recommend that any charges be brought about against the police officers involved, and WA Police Commissioner Karl O’Callaghan quickly confirmed that no further action would be taken. Four officers involved were sanctioned in 2014, and many have since been promoted.

The coroner did however rule that the “profoundly disturbing” CCTV footage of Dhu’s final days be released to the public, something her family has pushed for recently.

“The family wanted the nation to witness how their loved one was treated, they wanted the solidarity that would come with not having to grieve alone,” Barson said. “They also wanted solace and hope that would come with a public outcry in response.”

“She was treated as if she were an object, as if she was invisible, without regard for her dignity as a fellow human being,” the coroner said.

The final hours at the medical centre have not be released, but Barson says it’s hoped that the footage will spark further public outcry similar to that which followed Four Corners’ Don Dale expose, and leave the government with no choice but to act.

“I sat with the family when the footage was played in court,” she said. “It’s harrowing, it’s nightmarish and it’s incomprehensible how somebody could be treated in such a cruel and inhumane way.

“Unfortunately sometimes seeing is believing for many people. Images can really impact people in ways that words don’t necessarily have the same cut through.”

For Dhu’s family, the fight for justice and accountability continues.

“I came here hoping for justice,” Dhu’s mother, Della Roe, said outside the court. “And I still haven’t got it.”

It remains to be seen whether the government will act on the recommendations handed down by the coroner, or whether the death, revealed in all its gory detail to the Australian people, makes any difference at all.

“Western Australia is one of the only jurisdictions that doesn’t require reporting against a coroner’s recommendations,” Barson explained.

“It’s entirely possible that the government never responds, let alone implements the recommendations. That would be a really devastating outcome.”

More than two years after Dhu’s death and Barnett’s solemn promise to her mother, the coroner’s inquest, for all its flaws, provides a clear, nearly inescapable chance for him to deliver on this oath.

“[The Premier] eyeballed Della Roe and he promised he would do something,” Barson said.

“Now is his opportunity.”