Miss Dhu’s death was confirmed at the Hedland Health Campus on August 4, 2014. A decade earlier, Mulrunji Doomadgee finished up dead on the concrete floor of the Palm Island police watch house, November 19, 2004. The paperwork in these cases piles, the public attention continues but without fail we remain shy of justice and reforms. The findings of the coronial inquest into Mulrunji’s death compiled 35 pages. The record of the coronial investigation into Miss Dhu’s passing comprises 165 pages.

The first page of the read into 36-year-old Mulrunji’s death opens up with a summary of his partner’s statement to the court. Palm Island’s Tracey Twaddle had been with Mulrunji for ten years. “She described him as a having a positive outlook on life; proud to provide for his family and friends by his skills as a fisherman and hunter. He was not a troublemaker and had never been arrested on the Island.

They had looked forward “to growing old together.” On page 7, “There was at least one and half litres of blood and clot. The liver was virtually completely ruptured – ‘…cleaved in two’ in Dr Lampe’s words. The two halves of the liver were only connected by some blood vessels.”

Elliot Johnson QC wrote in the National Report of the Royal Commission into Aboriginal Deaths in Custody, “A death in custody is a public matter. Police and prison officers perform their services on behalf of the community. They must be accountable for the proper performance of the duties. Justice requires that both the individual interest of the deceased’s family and the general interest of the community be served by the conduct of thorough, competent and impartial investigations into all deaths in custody.”

In the Coroner’s report there was the usual swathe of recommendations – 40. But few have take-up. Recommendation 2 called for “the principle of arrest as a last resort.” The Coroner reflected, “The inappropriate arrest of Mulrunji reflects a lack of awareness of the legal bases upon which a person maybe arrested without a warrant.

On page 32, “Mulrunji cried out for help from the cell after being fatally injured, and no help came. The images from the cell video tape of Mulrunji, writhing in pain as he lay dying on the cell floor, were shocking and terribly distressing to family and anyone who sat through that portion of the evidence. The sounds from the cell surveillance tape are unlikely to be forgotten by anyone who was in court and heard that tape played. There is clear evidence that this must have been able to be heard from the police station dayroom where the monitor was running. Indeed the timing of Senior Sergeant Hurley’s visit to the cell suggests that the sounds were heard. But the response was completely inadequate and offered no proper review of Mulrunji’s condition or call for medical attention.

The coronial record of investigation into the death of Miss Dhu highlighted, “The Royal Commission provides a timeless reminder that every avoidable Indigenous death calls upon us to identify its underlying causes, consider Indigenous disadvantage, uncover the truth about the death and resolve upon practical steps to prevent others.

Western Australia, the nation’s backwater, continues to jail fine defaulters. In NSW, the jailing of fine defaulters was done away with in 1988.

Page 11, “Ms Dhu was the subject of four Warrants of Commitment dated 13 May 2014 issued under s53 of the Fines, Penalties and Infringement Notices Enforcement Act 1994 (WA) for fines and costs totalling $3,622.34 ordered by the various courts between 2009 and 2012.”

The Warrants of Commitment stipulated that the total period of imprisonment was to be four days (which was subsequently confirmed by the calculation conducted by Mr Rick Bond, formerly Sergeant Rick Bond, officer in charge of the SHPS).”

Miss Dhu was embroiled in a relationship where domestic violence prevailed. Police had been called out to an incident to support Ms Dhu and establish the peace, but instead arrested her for unpaid fines. The Coroner found, “I am satisfied that Mr Ruffin’s actions in throwing Ms Dhu over his shoulder were not a reasonable response to her inflicting a tiny wound to his leg which did not even require any medical attention, even if she did do that (and I am not satisfied that she did do that).”

As a result of backwater Western Australian laws that lock up fine defaulters, the Coroner reflected, “In respect of all these matters, Ms Dhu was reliant on police from the Lock-Up and clinicians from Hedland Health Campus. Her reliance upon them heightened their duty of care towards here. If the clinicians had determined that she required hospitalisation, in the ordinary course that would have occurred under police guard, HHC. This would have raised yet another set of considerations, which magnified the unusual nature of the presentation.”

For all these reasons arising as a consequence of Ms Dhu’s loss of liberty upon incarceration, the actions of the clinicians and the police were examined at the inquest.”

Regretattably the actions of some of the clinicians at HHC were affected by premature diagnostic closure, and errors were made. Ms Dhu’s suffering as she lay close to death at the Lock-Up was compounded by the unprofessional and inhumane actions of some of the police officers there. All of the persons involved were affected, to differing degrees, by underlying preconceptions about Ms Dhu that were ultimately reflected, not in what they said about her, but in how they treated her.”

In terms of ‘unprofessional and inhumane treatment’, on page 83 of the record of investigation, the Coroner reinforced Ms Dhu’s rights and humanity with Article 10(1) of the International Covenant on Civil and Political Rights, “All persons deprived of their liberty shall be treated with humanity and respect for the inherent dignity of the human person.”

The Coroner handed down 10 recommendations. How long before any of them are implemented? The Coroner re-emphasised the over-representation of Aboriginal women in prison for fine default. Page 145, the Coroner quoted the RCIADC, “Fines operate in a manner which is obviously unjust towards poor people, since the impact of any monetary penalty is directly proportionate to the defendant’s income.” In recommendation 6, the Coroner stated, “I recommend that the Fines, Penalties and Infringement Notices Enforcement Act (WA) (section 53) be amended so that a warrant of commitment authorising imprisonment is not an option for enforcing payment of fines.”

I hold the view that had Western Australia a Custody Notification Service at the time of Ms Dhu’s arrest that a CNS advocate would have saved Ms Dhu’s life. I have written widely about the need for such a service to be established. Recommendation 10 called upon the State Government to give “consideration as to whether a state-wide 24 hours per day, seven days per week Custody Notification Service based upon the New South Wales model ought to be established in Western Australia.”

Nearly 13 years ago, Mulrunji Doomadgee was bashed to death in a Palm Island police cell. Mulrunji was the 147th Aboriginal death in custody since the RCIADC final report (1992). Ms Dhu became the 340th. There were thereabouts 100 Aboriginal deaths in custody in the ten year period from 1992 and nearly 150 deaths in custody in the ensuing decade, with nearly 200 deaths in the ten years since Mulrunji’s passing and to Ms Dhu’s loss.

There is a school of thinking that argues Black deaths in custody are decreasing – this is drawn from proportion to numbers of Aboriginal and Torres Strait Islanders detained and incarcerated. The Black prison population is escalating. But another school of thought argues that Black deaths in custody are increasing. This is based on the crude total number of custodial deaths I have described in the preceding paragraph. What is certain is that nearly all deaths in police lock-ups are of Aboriginal and/or Torres Strait Islanders.

Nearly three and a half decades ago, an inebriated off-duty police officer killed 16-year-old Yindjibarndi John Pat. Western Australia’s remote township of Roebourne became known to Western Australia with the same alarming darkness that two decades earlier Birmingham had become for Alabama. Recently, the Queensland government and police were found to have acted as racist after a Palm Island class action in the courts.

John Pat’s mother, Mavis said, “My son did not have to die… they did not have to kill him.”

John Pat died because he was Black – because of the colour of his skin, because of racism. Four off-duty police officers and an off-duty police aide belted into half a dozen Roebourne youth, all of them Yindjibarndi. Minutes before the fight, one of the coppers had said to one of the youth, Ashley James, “We’ll get you, you Black cunt”. The copper followed him out of the Victoria Hotel and laid into him, a brawl took shape. John Pat stepped in to pull his mate Ashley out of harm’s way. The police offer launched into John Pat.

John Pat’s aorta was torn, his bones broken – his body bruised and battered. He fell backwards to the red earth.

At brawl’s end, with on-duty police having arrived, John Pat was “then tossed” it was said by a witness “like a dead kangaroo into the back of a police van.”

In a police cell, officers would wash down his body and change his clothes before ‘investigators’ viewed him. The five police officers were charged but despite the volume of evidence which included falsified charge sheets and false testimonies an all-White jury in another bullshit decision acquitted them – found them innocent.

During the commencement of the Royal Commission into Aboriginal Deaths in Custody Mavis Pat said, “I don’t know what is going to come out of the Royal Commission but I hope it makes everything better for Aboriginal people.” Two decades later Mavis said to me, “Nothing has got better, if anything it is worse.”

There are a number of issues that can be seen to have contributed to people locked up, convicted, who die in custody. But many have been locked up, convicted, died in custody because of issues borne of racism. There might be a more fair-minded society today than yesterday but the fair-mindedness has not been soaked up institutionally and structurally and unfairness and discrimination still get their say. Racism got Ms Dhu locked up. Racism prevented her life from being saved. Racism killed Mulrunji. Racism got John Pat bashed and dead.

There is still a long way to go.