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The Tony Liristis Case

The Tony Liristis Case

Mr Liristis sought orders that his solicitors supply him with a laptop while in custody in order to prepare to defend himself against current matters before the District Court. However, concerns surrounding prisoners having access to the Internet or charging their mobile phones have prevented him from having access to this technology. Peter Severin, the commissioner of the Corrective Services NSW (CSNSW) refused Mr Liristis’ request due to “security concerns.”

He was representing himself in the matter, which had to be rescheduled twice due to the inadequacy of resources. Whilst the fears about computers in cells is plausible, it restricts prisoners’ ability to have a fair trial and in turn does not comply with the explicit terms of the ICCPR.[1] In light of the violated rights, a court proceeding granted Mr Liristis access to a printer and computer in custody in order to prepare for his appeal.[2]

[1] International Covenant on Civil and Political Rights (n 1).

[2] Australian Law Reform Commission, Traditional Rights and Freedoms (Report No 129, March 2016) 219-57.

Report on Inquest 7 March 2019

NSW Coronial Inquest into the death of David Dungay
Deaths in Custody
Day 4 Wesnesday 07/03/2019


  • Dungay died of Asystole (loss of oxygen eventually leads to the heart stopping beating and leads to cardiac arrest). He was depleted of oxygen primarily (rather than ventricular fibrillation or genetic causes) and there were numerous contributory factors to his premature death.
  • There is no basis of a genetic predisposition relation to oxygen nor heart function
  • Blood sugar levels swung to very high just before he died.   Hypoglycemia can be life-threatening and can significantly add as a compounding deleterious effects to asystole.
  • Death caused by asystole is confirmed ie heart stops due to lack of oxygen, and this occurred after he struggled with CSO
  • ‘Chemical storm’ of three medications not the cause, but was likely to have affected his premature death by cardiac arrest as can increase cardiac dysrhythmia
  • Medazolam as a substance was unlikely cause of death
  • Clear signs that Dungay maintained a struggle, and the sudden nature of his death included hypoxia/asphyxia
  • Head Concussion has not been ruled out was a possible factor – Neuro-pathologist report?
  • Dungay’s neck being placed on the edge of the bed could have contributed to his death
  • Autopsy Report confirmed ‘quite marked congestion to the head’ that is due to some kinds of pressure- cant report why . This congestion pertains to head/chest pressure stopping blood flow, that then stops heart beating and person dies of cardiac arrest.
  • Autopsy Report considers cause as cardiac arrest due to hypoxia, and summarized as that any single, isolation of factors is not indicative of cause of death, however in combination, concluded is ‘maybe, uncertain’.
  • Autopsy Report isolated various negative factors that may have caused or contributed to Hypoxia such as: pressure to body areas like the neck, bruising and haemmorages, dehydration, if he was beaten up, Ketone Acidosis.

Witness 1 - Consultant Cardiologist, Associate Professor Adams

Causes of death

Dr Adams presented his evidence in relation to the factors that may have been related to or caused the premature death of David Dungay. This included analysing ECG data, wthe effect of medication he was on, the timing of when hypoxia (the heart stopped beating) was likely to have happened. In particular, he considered the factors that could potentially have deleterious effect on the electrical conductivity of his heart and caused asystole to occur. The QT Interval is the normal expected time rhythm of the heart to contract and pump blood through, and the effect of some dysfunction of the heart is marked by an increase of the QT Interval .

Key matters related to the presence or likelihood of damaging effects to Dungay’s health with regard to his QT Interval including the likelihood of effects of: stress, and either internal - such as a genetic disposition, or medically induced causes - or externally induced hypoxia (reduced or insufficient oxygen)[1].

He stated that the QT Interval can vary with Blood Sugar Levels, and that at 7 am on the day he died, BSL was 6.3 which is low but in OK limits. He noted there was a BSL swing from high to very high just before he died up to 20-25. It is ‘quite possible’ that his QT Interval would have increased with this swing.

He considered the potential of any genetic factors impacting, but concluded there were no indications of this in his or his family history, nor of him having any “Long QT Syndrome’, stating ‘Not suggesting at all that he had a genetic disposition – we don’t know’.  ECG’s show he is unlikely to have had a genetic disposition.

Based on the 2 ECG’s he said we may have increased QT Interval simply from what we understand about the medications Dungay was on, and this was likely to have affected his premature death.

He summed up that rather than any initial problem of ventricular fibrillation, Dungay most likely suffered asystole (the heart stops beating) seconds before he loses consciousness. He noted a consistency in that when Mr Ma had found a ‘very weak pulse’ it was probably a short time to asystole.

Dr Adams explained why he thought it was likely that the arrhythmia did not start when Dungay was in the first cell but rather at a later stage, an important sign being his capacity to struggle eg sustaining a struggle with five guards, his labored breathing and shortness of breath as he said ‘I can’t breathe’, getting out of the leg lock, showing ‘amazing strength’.  This indicated that the asystole occurred after the struggle, as he could not have had the capacity to struggle if it came beforehand.

Dr Adams also referred to the additive effects on increasing QT Interval due to medication, and described it as a ‘chemical storm’ that significantly would have increased the QT Interval, thus the struggle and the medication he received would have had a compounding effect.

He noted that there was food in the lungs indicative of aspiration of the stomach contents during resuscitation.

Also, he noted that congestion was in the lungs, rather than in the head. The Autopsy report showed ‘petachial haemorrages’ that can be present with prolonged straining, caused by some way that produced increased thoracic pressure that can stop the blood flow, such as congestion to the head and upper chest. These haemorrages can be caused by compression being applied to body during CPR, but he said there was no such resultant congestion was relevant to his thinking.

10:40 AM: Professor Adams in court

  • Kept stuttering when talking about his death
  • He had two theories for his death.
  • Shortness of breath in first cell
  • Shortness of breath started significantly later
  • He had little doubt he was exerting himself and after one minute he was breathing differently
  • Professor Adams thought that there were pre-disposing factors that led to David Dungay’s passing. He thinks it was side effects from psychosis medicine.
  • Whilst there was no clear cause of death (according to the autopsy), Professor Adams thinks that David Dungay had heart arrhythmia as his death was sudden and not slow (From observation that David Dungay turned blue from lack of oxygen quickly not slowly like hypoxia)
  • Professor Adams  stated restraining or struggling against someone stops the blood return.
  • Professor Adams stated the two psychosis medications together with diabetes increased the likelihood of this.
  • Professor Adams observed and stated prolonged congestion in the head, shoulders  however, has no comment.
  • He stated food on the lungs from the autopsy orbited from the stomach in resuscitation.


Witness 2 - Forensic Pharmocologist Consultant, Mr John Farrah


Mr Farrah had listened to the evidence above by Professor Adams, as well as attended to the Autopsy Report . He analysed the chemical substances and their potential involvement in Dungay’s death, including the injection of Medazolam, and the three antipsychotic drugs he was treated with therapeutically.

Mr Farrah concluded that he can make a good estimate regarding the rapid sedative, Medazolam (forced medication delivered as a intramuscular injection of a rapid sedative): that while found in the body was negligible and under the reportable level, and at a sub-therapeautic level. If Dungay’s collapse did occur within 1-2 minutes after receiving the intramuscular injection, it would have had a negligible effect.

The three anti-psychotic treatments were all at therapeutic levels or a bit higher. One drug Chlorpromosine (?) would have had a sedation effect. Zoopathixol (??) had no sedative effect but we could expect would increase QT elongation (ie adversely affect heart rhythm, as per Professor Adam report above, to which he would defer to). Mr Farrah concluded that the three antipsychotics were unlikely to be a cause of Dungay’s death.

Also, that the antipsychotic drugs taken alone would have not increased the QT Interval (ie on their own, affected his heart beat).  [Noted discrepancy: Prof. Adams stated a likely deleterious effect of these chemicals, adversely compounding on his QT Interval. However, Mr Farrah noted, he did not have a PhD nor the expertise Prof. Adams has, thus to defer to Adam’s opinion.)

It was noted that at autopsy compared to when Dungay was alive, substance levels were likely to register as slightly up, not down.

12:04 PM: Dr. John Farrah in court 

  • Stated that he has seen a media report showing the video after he prepared the toxicology part of the autopsy report
  • Toxicology segment showed that:
  • David Dungay had antipsychotic medication at therapeutic levels (level administered is really dependent on the circumstances could be administered in. For example, a person can be administered a higher than “normal” dosage for something if the person would be under strict supervision)
  • Dungay was injected with 10MG(?) of Midazolam > This dosage is considered to be on the higher end of the therapeutic range (even for David Dungay’s weight)
  • First usage of defibrillator was 5 minutes after David Dungay’s death.
  • Note : He was stuttering when questioned.
  • Dr. Farrah believes that:
  • The amount of midazolam administered contributed to Dungay’s death
  • Believes that little midazolam entered his blood (low bioavailability),  due to being injected in the gluteus muscle. The midazolam may not have entered the bloodstream properly but entered into fatty tissue instead. S response was 2 minutes.
  • Dr Farrah stated that Dungay would have a built up tolerance to  Midazolam and that it would have no significant sedative effect on Dungay. Dr Farrah suggested Chlorpromazine is known to cause this effect.
  • He also stated he didn’t have access to the video or much information in allegations to restraint.
  • Stated an average response is 45 minutes however Dungay’s was 2 minutes.

Witness 3 - Pathologist who conducted the Autopsy, Dr Bailey

The compression

Dr Bailey considered a range of factors in her Autopsy Report, including for example, bruising of the head, which was unidentified, but where concussion was a possible effect.   She summarized that in isolation factors she considered where not indicative of cause of death, however in combination, that her conclusion was that the factors considered were ‘maybe, uncertain’.

Dr Bailey detailed any noticeable damage on various regions of the body that indicate compression or damage such as bruising or haemorraging. She was unclear – ‘cant say’ - of any evidence of blood in the mouth, but there was lots of vomit, despite prolonged resuscitation. There was a small amount of haemorraging that may have occurred if head turned, but not significant enough to say was neck compression of injury. There was ‘quite marked congestion to the head’. The head and neck showed minor injuries.  

Diabeties related Ketoacidosis[2] was excluded as a cause of death, as [unspecified what level] levels were below cases she has seen.

Autopsy findings were of no pathology or ‘unascertained cause of death with several attributions’.   She can see mechanical chest and neck compression, and that increased blood pressure that led to rupture, causing haemorraging. Compression can cause blood failure to drain from out of the head, but no conclusive evidence as she can’t conclude if compression of neck was due to prone position.

She can see that compression is evident but can’t say why - eg CPR or prone position. Congestion of scalp corroborates with petechial haemmorages that blood into head but whether it is because of prone position, restraint, cardiogenic (?) shock, or maybe a combination of the above.  

She noted the CSO/IAT use of the knee ride was a potential mechanism, but can’t confirm that this was a cause of death.

Dr Bailey summarized important aspects when considering cause of death: heightened agitation as a signal of some kind of dysfunction, some obesity, diabetic, held face down, and that the effects could be cumulative. Such cumulative effects cold be where: blood oxygen level was down, plus possibly some dehydration (if had high BSL then dehydration can add to physical distress), plus placed under higher metabolic challenge.

Adding to the above, the combination of antipsychotic medication, many of which can increase cardiac dysrhythmia. She recommended we refer to the Cardiologist for this matter [and if we check above, Prof Adams did state this could have compounded and had a likely deleterious effect on heart beat rhythm].

Dr Bailey stated that the path to hypoxia with metabolic demand is already high ie affecting oxygen levels. Also, we cannot exclude that the cardiac arrest was induced by hypoxia. [See Emergency Specialist, Prof. Brown’s July 2018 evidence where he stated this as the cause of death.]

By way of summary, Dr Bailey concluded that the combination with the heightened agitation and the altercations he had with CSO, these numerous effects would have contributed to his heart going into further strain, with ‘lots of small things in combination can have an effect in this case’.

She added that Dungay’s neck being placed on the edge of the bed ‘could be contributory’.

Considering whether Dungay was beaten up, she said there are small, minor effects, but she can’t say if they were inflicted by another person in altercations, and if they were she didn’t see any signs of this as a significant contribution.

She asked herself if the police report matched with her inquiries with a neuropathologist to see if there was any brain damage/trauma - however her conclusion was not clear. She made note of rib fractures that may be common with standard CPR delivery [however positive CPR delivery was not adhered to for Dungay].    

Dr Bailey said she could ‘not see serious injury at post-morteum’, and that there were far too many contributing factors to the causes of death.  She is in no doubt that cardiac arrhythmia occurred, when being aspiration, in hypoxia or atoxia, and that she cant give certainty to know why he suddenly collapsed.

For a non-diabetic person the normal rate of ketones is between 55 – 150, as the upper limit of fasting level. She reported that the biochemical analysis of Dungay’s Ketone Acidosis shows 151 micros and concluded this was below level of Diabetic Ketosis.

1:45 PM: Dr. Kendal Bailey in court

  • Viewed the footage prior to post mortem however, didn’t have access to CPR footage of what happened before conducting autopsy. The video was provided to her by the police so she could corroborate the events that happened in the video with the injuries that were showed in the autopsy.
  • Note: Bruising on the head makes you concerned about concussions
  • Note: Injuries to the mouth might reflect compression to the nose and mouth
  • Note: Bruising is very difficult to date
  • The injuries that were shown in the autopsy report were:
  • Y shaped Laceration between the eyebrows → minor skin injury, occurred when entering the first cell where his head came into contact with a shield
  • Lesions on the forehead with bleeding on the right side
  • Purple discolouration on left eyebrow → acute bruising
  • Red-purple abrasion (scrapte type injury) on left eyebrow
  • Superficial scratch marks on the right cheekbone
  • Intramuscular hemorrhage on the jaw muscle
  • Multifocal hemorrhage to the muscle from the sternum to the neck (which helps a person turn their head)
  • Scrape injury → some skin loss to the medial surface of the right forearms
  • Both wrists showed bruising → may be due to handcuffs
  • Pink bruise on the back of the left hand
  • Bruising on both knees
  • She considers these injuries as “minor injuries if they were in isolation”
  • Dr. Bailey thinks that he passed because:
  • Heightened agitation/stress = Increased heart rate → can lead to cardiac death
  • Blood oxygen level went down = due to being compressed (abdominal organs compressed → harder for blood to drain from the head)
  • Those two were compounded by his diabetes and obesity
  • These then led for him to have a cardiac arrhythmia
  • Whilst giving her thoughts as to what the causes of David Dungay’s death, she uses the words “possibly”, “could have”, “maybe”, “not conclusive”, to demonstrate that she really isn’t sure what the causes are and doesn’t want her word to make her accountable to conclusively determine the cause/causes. For example, “the bruises on his knee could have been due to compression, but I don’t want to conclude it as that as people get bruises on their knees all the time”
  • She stated injuries don’t exclude the possibility of minor altercation with another person.
  • Dr. Bailey was asked how does an autopsy take place. She stated:
  • That the autopsy took place a day after his death
  • Steps included:
  1. Medical imaging through CT scans
  2. External examinations: to find evidence of cuts, bruises, any injury that could be found on the surface of the skin.
  3. Internal examination: involves looking at evidence of injuries on the organs and muscles of the body. She would take a sample of each tissue and look at it through a microscope
  • She stated that she needed legal permission from the coroner to perform the autopsy

Conclusions from the observation:

  • If David Dungay wasn’t physically restrained, he wouldn’t have a cardiac arrest.
  • Seems like the lawyers want ONE conclusive cause for his death (most likely lack of oxygen), but if there are a multiple amount of causes compounded, then that should be utilised as well
  • However, a death by one thousand cuts is still a death
  • Currently, the family thinks the causes were: External pressure, cardiac arrhythmia (can’t determine the cause of this)
  • Observation : Family prepared statements and media application however opessission are trying to delay by requesting to see it first. The coroner previously stated the family can provide a statement as long as they don’t use defamatory language and pin point names.
  • Questions to think about:
  • Why didn’t they show the photos from the autopsy?
  • Why are they unable to settle on the cause/causes of death?
  • Why was the evidence inconclusive?
  • Why wasn’t the Aboriginal liaison officer called to speak?
  • Why did the correctional officer breach the protocol of cell transfer (usually need permission and need to document that the cell transfer for an inmate would occur but it didn’t)?

Court adjourned 3:06pm on the 7th March 2019.


[1] Hypoxia (environmental), reduced oxygen content of air or a body of water detrimental to aerobic organisms

Hypoxia (medical), a pathological condition in which the body or a region of the body is deprived of an adequate oxygen supply

[2] [Life-threatening condition associated with very high BGL, where the blood produces acidity in body when insufficient insulin. See https://www.diabetesaustralia.com.au/ketoacidosis]

Report on Inquest 6 March 2019

Coronial Inquest into David Dungay

Deaths In Custody

DAY THREE 06/03/2019


  • Main topic of the Inquest was the Working Group (WG), established in July 2018, after the first round of Coronial Inquest proceedings. The WG is a joint effort between Justice Health (JH) and Corrective Services (CS) to create standards of procedure in relation to forced medication and restraint.
  • Main lines of questioning attempted to highlight the inadequacies of the two ‘Local Operating Procedures’ (LOPs) documents created by the WG.
  • Little demonstration of signs of the WG’s efficacy in resolving the pre-existing problems of operational procedures that were involved in Dungay’s death.
  • Questioning of the interagency working procedures between JH and CS.
  • Counsel concluded that there was no evidence of the practicalities of operations practices being addressed. 

Below is a summary of the evidence given by two key witnesses in the case.

Witness Statement 1: Sean Connelly (Head of the WG)

Sean Connelly joined JH in August 2016 and started working with Long Bay Hospital (LBH) in 2017. He had a managerial role and was part of the WG, having attended all four of the WG meetings.

The Counsel assisting the Coroner stated that it was clear that the WG was created in reaction to Dungay’s death in custody, as the major issue was Restraint Policy Procedures.


Connelly gave evidence that since he started working in LBH, two years ago, he had not witnessed any specific training on the official NSW Health Policies. However, nurses and hospital staff had undertaken training in areas derived from the NSW Health Policies, including violence prevention training.

“Doctors are responsible for their own training,” Connelly said. In terms of accountability in cases such as this, he said the end point would be Dr Ellis, the Clinical Director, who was unfortunately denied leave to be a witness by the Coroner.

There was a training day held on the 2nd of January at LBH where newly drafted LOPs were trialled. According to Connelly’s estimates, about 50% of the JH and CS staff would have attended this event. There were also plans for future training events, regarding the LOPs.

The WG

The WG had visited sites external to LBH, including the Prince of Wales and St Vincent Hospitals, which informed their drafting of the LOPs. The visits were not necessarily to the mental health wards themselves, but rather meetings with official staff at the two locations.

LOP considerations

Connelly gave evidence that the WG discussed alternatives to ‘Prone Restraint’, the physical type of restraint used on Dungay which prevented him from breathing. Alternatives included ‘soft restraints’, as opposed to the use of cufflinks. WG had not considered whether individuals other than CS officers, such as JH nurses or private security, should undertake restraint.

The LOPs drafted by the WG state that CS could undertake enforced medication after attempting to get permission from a psychiatrist. In G Ward, psychiatrists are available on-site from 8am to 4:30pm on weekdays and weekends with an on-call doctor available after hours. The LOPs do not require the on-call doctor to attend the administering of the medication. Connelly stated that there is only ‘a preference’ that they attend.

Connelly acknowledged that tension exists between JH and CS, regarding who has the final say in emergency restraint situations.

“JH and CH are jointly responsible for ensuring restraints are safe,” he stated.

Inconsistencies in the wording of the LOPs were pointed out. Connelly seemed to agree that the LOPs should explicitly state whether JH staff have the capacity to give directions, which can be followed by CS staff, regarding the safest restraint position to use in emergency situations.

Patient out-times and time-out in solitary cells

Patients in the G Ward only get one to two hours out of their cells per day. The WG did not discuss improving these conditions. Connelly stated that cells had been refurbished for the purpose of ‘time-out’. But there was no capability of using them, as they were in an area with inadequate nursing and CS observation.

Connelly’s personal reflections

Nearing the end of his questioning, Connelly stated that the nature of care in G Ward had changed after Dungay’s death in December 2015. Safe and effective care for all patients was a priority across all of LBH, particularly within the mental health ward. He regarded the partnership between JH and CS to be fundamental, believing it to be transforming into a joint process. For Connelly, the WG was an important aspect of this change.

Connelly stated that the evolving ‘simulation processes’ with joint JH and CS training are planned to begin in April 2019 with an unspecified audit to determine compliance.

He ended his examination by apologising to Dungay’s family, affirming that ‘safeguarding the processes’ undertaken by JH and CS was key in ensuring better care for their patients in the future.

Witness Statement 2: Andrew Martin Godfrey (Acting General Manager of Custodial Corrections)

Godfrey was the Secretary of the WG and the Acting General Manager of Custodial Corrections (Projects Management). He had limited ability to provide useful evidence to the Inquest and did not hesitate to inform the court of that.

Despite attending all WG meetings as Secretary, Godfrey maintained that he was not involved in their site visits or the drafting of the LOP. He had never worked in the hospital, thereby emphasising his lack of experience or knowledge in answering many of the questions put to him.


Godfrey stated that the LOPs have been in place for about 30 days. There was a trial and training day on the 2nd of January, involving a review of the LOPs and simulations on-site. He did not know the details of the content covered in the training sessions.

Godfrey believed CS would continue to work with JH and that more WG meetings were likely. He could not give any indication about when the next meeting would be or how many would be scheduled. He stated that there was a ‘reasonable assumption’ for any issues identified with the LOP, including concerns brought up during questioning in the Inquest, to be considered by the WG.

The Coroner conceded that this witness was not best placed to answer questions about how the LOPs would be practically implemented by CS, being the reason he was called to give evidence. The next witness in line had already been sent home earlier in the day. The day’s proceedings were therefore adjourned early.


In the afternoon of Day 3 of this Inquest, substantial time was spent arguing about which WG member was a suitable witness as well as the Dungay family’s request for Dr Ellis. Not only was Dr Ellis a WG member, he also possessed considerable clinical experience in areas such as training psychiatrists and psychologists. JH and CS legal representatives insisted Connelly and Godfrey to be suitable witnesses for cross-examination but Godfrey proved unable to answer many questions put to him.

It seemed especially unfortunate that Dr Ellis had been denied as a witness in the Inquest because his name was mentioned quite often in the questioning that occurred today. It is likely that Dr Ellis could have been able to offer greater insight as a witness.


Please see DAY FOUR for a continued recount on this Coronial Inquest.

Report on Inquest 5 March 2019

Coronial Inquest into David Dungay

Deaths In Custody

DAY TWO 05/03/2019


  • Lack of Medical Intervention: Categorised within forced medication
  • Lack of training for authoritative Correctional staff dealing with prisoners
  • Failure in identifying the ramifications associated with the medical intervention towards David Dungay
  • Errors in medical judgement

Below is a summary of the evidence given by three key witnesses in the case

Witness Statement 1 – Dr Ma

Dr Ma was an accredited medical practitioner who initially carried out the forced medical treatment on David Dungay. Dr Ma was aware of the medical condition of David Dungay and has intervened in this treatment.

Identifying traits in patients medical condition:

Dr Ma reiterates that the patient has ‘impaired judgement.’ From this case it would be relevant to consider that David Dungay’s behaviour and medical diagnosis is relevant in proving the mitigating factor of this case; as he acts impulsively rather than rationally due to the mental impairment associated with his medical condition.

Errors in medical judgement

There was no accredited third party auditing service provided in regards to emergency training practices. In addition, professional staff failed to de-escalate the patient’s aggravated behaviour, resulting in a breach of their level of care. In regards to this case, there was a failure in liaising directly with professionals within the appropriate hierarchy stipulated, resulting in a lack of confidence within the Health Department. David Dungay’s state of vulnerability was exacerbated by the neglect of staff officials in making appropriate observations of his physical state.

In regards to the CPR medical training prerequisite, Dr Ma further corroborated that it was an “Appalling attempt at resuscitation,” and that it was certainly not up to his standards.

The liability falls against Dr Ma, as the medication to be administered was beyond the duties of the Nurses, yet Dr Ma still instructed them to administer it. The argument in which defends the initial purpose of Dr Ma’s actions is that these nurses were highly experienced and he believed that they could undertake such tasks. Dr Ma believed that his area of control was in reading the notes and assessing the circumstances.

Witness Statement 2  Chief Trainer for Justice Health Staff; Mr Sontag

Mr Sontag is affiliated in the field of health and is a Chief Trainer for Justice Health Staff, including nurses. Mr Sontag was involved in the case of David Dungay, whereby he administered the training and education of the Nurses. Sontag is involved in various training programs; such as the ‘Myrtle Program’ and other various initiatives.

Lack of training and education for Nurses

The lack of administering the appropriate approach to training and education was evident, seen through the inadequate procedures undertaken for CPR on Mr David Dungay. This is highlighted through the role of Nurse Maharja, who was cross- examined about the training content on the 04/03/2019.

The lack of induction training and education is clearly indicated through the inadequate intervention in possibly saving David Dungay’s life. Mr Sontag confirmed that the video evidence showed that there was difficulty in air passage. He confirmed that the cap was left on the suction device, as well as the neglect in examining who was responsible for this. Mr Sontag reiterated the notion that there is a prevalent issue in the structure of leadership within nursing practices, which demonstrated a lack of confidence.

Compliance with Australian Standards

Mr Sontag affirmed that there is no audit of medical emergency training practices, as he stated that these incidents are quite rare.

Witness Statement 3 – Ms Sheehan

Ms Sheehan is Deputy Director of Midwifery and Custodial Services. She presented existing health policies on Enforced Medication.

Policies for Medical Practices

Ms Sheehan stated policies in relation to PRN medical patients, the need for de-escalation actions by nurses, and the Enforced Medication and the Emergency sedation policies and practices. She recommended for these policies to be brought in line with current NSW Health Policies.

Ms Sheehan further gave evidence that a nurse could make a decision in regards to intramuscular injection of midazolam on a PRN patient such as Mr David Dungay.

Report on Inquest 4 March 2019



David Dungay Image 2


Coronial Inquest into David Dungay

Deaths in Custody  

DAY ONE 04/03/2019


  • Significant lack of training for correctional and medical staff in emergencies that require intervention.
  • Uncertainty surrounding Dungay’s behaviour and the extent of his aggression.
  • Witnesses reluctant to take responsibility, admit guilt or fault.
  • Revision of sedation/enforced medication policies and other safety procedures.
  • Unjustified choices/doses of medication used.


Below is a summary of the evidence given by two key witnesses in the case.

Witness Statement 1 

Relationship with Patient

To open the inquest, Rajana Maharja was brought to testify her movements during the death of David Dungay on the 29th December 2015. Rajana was a nurse at the correctional facility where David Dungay resided. Maharja explained that her prior dealings with Dungay were “occasional” and of which she recalled she knew him as a patient in Ward G of Long Bay Hospital.

Diabetes Management

On the date of the death, Maharja stated that the nurses (Zhu, Thapa and Newman), doctor (Dr Ma) and herself were all knowledgeable of the concern surrounding Dungay’s diabetic management. This included the fact that Dungay had consumed rice biscuits and as a result, quickly became agitated when instructed to stop consuming by a custodial officer. Nurse Zhu recounted this incident to her.

Maharja was questioned on what occurred after she had this conversation with nurse Zhu. Maharja claimed that she spoke to unidentified officers who requested Maharja write a medical certificate that would allow Dungay to be moved to a camera-cell.

Maharja told the court that her only concern with the biscuit incident was in regards to the risks it posed to Dungay’s sugar levels, which would be expected to fluctuate. Being a ‘clinical issue,’ Maharja expressed that this was a “clinical issue” which did not need to be dealt with by placing Dungay in a camera-cell – her opinion was in opposition to the custodial officer’s who intended to increase observation of the innate as per ‘procedure.’ 

Response to Patient’s Agitation

Maharja explained that she was located in the medication room when the ‘duress button’ sounded. Maharja claimed that herself, nurse Newman and Doctor Ma responded by beginning to resuscitate Dungay.

There was no indication in testimony of how, who or when the duress button was pushed, or if protocol was being followed as per outlined in Doctor Ma’s testimony (vitals being checked every 15 minutes until mobilization).

When asked what her role was in the resuscitation of Dungay, Maharja stated that she had great difficulty in recalling and expressing her actions due it being a high stress situation. However, she described her primary role being to maintain the airway by holding the jaw open and to get the air bag valve mask. She was prevented from doing so due to the excess amounts of thick vomit that was caused by the biscuits he had digested.

Nurse Newman assisted Maharja in opening the however, claimed that the food particles became too difficult to remove, and so attempted to perform a ‘hand-held suction.’ Maharja also states that Nurse Thapa came from another ward to assist – she does not recall her primary role in the incident. According to Maharja, Dr Ma was performing chest compressions.

Emergency Specialist Dr Brown has since criticised the actions of those involved in the resuscitation incident as adequate ventilation was not consistently provided to Dungay.

Questioning the Witness

Maharja was asked about her qualifications in CPR. She explained that the incident was her first experience performing CPR in a real emergency situation and not in simulation or educational role plays.

When asked about her training for emergency CPR since this incident, she struggled to recall when or what training she had completed in reference to new policies instigated by Justice Health. However, Maharja did state that a new team leader was appointed in the area of Emergency Training Services. The leader’s role is to ensure adequate execution of response checklists and foster more collaboration between Justice Health staff and Corrective Officers.

Maharja did claim to do further simulation based scenario training following the incident. When asked what she would have done differently in the incident, she said these new policies and plans would be implemented. Maharja and staff are alerted to changes in framework via headboards/emails. The discussion of frameworks was vague - Maharja has not been in similar situation of emergency resuscitation since 2015.


At this point the court had a break and the conclusions are as follows:

There has been poor training in respect to roles and responsibilities in areas of sedation and joint intervention - evidence drawn from witness statements demonstrates inexperience and incompetence.

Restatement of Facts

As court resumed, Maharja was once again questioned on her knowledge of the transfer, to which she claimed she was in the nurses station and did not see the transfer of Dungay from a non-camera cell to a camera cell.

She was also further questioned on her resuscitation training to which she added information about her first year of Nursing which included scenario based training at Long Bay Hospital learning centre. This detect training incorporated CPR training - the CPR coordinator acting as one of the educators in this course which she completed some time after starting in March 2013. Records from Justice Health indicated that she had not completed training since the 8th of April 2014, 20 months before Dungay’s death.

In response to not having completed a refresher course of CPR, she claimed she was on annual leave and not aware that her CPR course had lapsed, to which both parties are responsible to follow. Even though she had not done any practical CPR training in the fourteen months preceding Dungay’s death, she claimed to be confident in her skills as she had been assessed and checked whether she was competent or not in being assessed on a mannequin previously.

Maharja was questioned again about her roles during resuscitation (resuscitation lasted 17 minutes). Maharja claimed she and a colleague were working on the airway at the same time. Additionally, Maharja mentioned that at one point, a defibrillator was used on the victim’s chest. She was asked how long it takes for a defibrillator to deploy based on her experience, she could not answer for sure. She also cannot recall why there were long pauses taken between the 30 compressions and 2 breaths that should not have occurred (in line with proper CPR practice). She could not recall who completed the suctioning, or that a cap was left on the suction device, which was later found in Dungay’s mouth.

Following the Event

Maharja was asked whether she had continued to work in G Ward after Dungay’s death, to which she has (continuously and reasonably). She has also worked in the E and F Ward which are Mental Health Units.

Maharja was questioned on how practices have changed in enforced medication since Dungay died, to which she claimed there was now joint intervention with custodial services, and less enforced medication policies. She was also asked about the use of safety huddles in the Ward, which she claimed to occur at around 9-9:30 in the morning when doctors are around, however, was unsure whether these were used at the time of Dungay’s death.

Witness Statement 2

At this point, Dr Trevor Ma was brought in to answer questions. His representation raised an objection and under section 61 of the Coroner’s Act, to giving evidence regarding any aspect of the resuscitation unless provided with a certificate under 61(5) which would deem him potentially liable to civil penalty if the evidence proves. This certificate was granted.

Dr Ma offered condolences to the family, and wants to know more information about what occurred on the 26th December 2015. Dr Ma was a Psychiatric Registrar in 2015 working at the Long Bay Hospital for Justice Health, however is now working as a Staff Specialist at the Forensic Hospital adjacent to Long Bay Hospital and Silverwater Mental Health Screening Unit.

Details of Events

Dr Ma claimed that on the 29th December, a call was made by nurse Newman to raise the fact that there had been an attempt to move biscuits from Dungay. He did not know if this has occurred by physical means or a verbal de-escalation. He approved 10ml of midazolam and also 10ml Haloperodol to sedate Dungay based on his levels of aggression which the nurse has described as high. He was aware of Dungay’s diabetic condition.

Prescribing Medication

Dr Ma was asked whether about practices which involve examining the prisoner before prescribing - he claimed that there was a need to review Dungay, but it could be done before of after, as a review can occur after the mediation is administrated depending on the immediacy of the risk.

He was also asked to determine what was required in observations of the inmate following the administration to which he replied that prior to administration observations included – decreasing levels of consciousness, acute medical conditions, particularly off airway and breathing conditions and vital sign observations if possible. Following the administration of medication the patient should be continually observed every 15 minutes until the patient is mobilised.

Dr Ma also claimed that flumasinol injections were not available at this time (evidence to counteract an overdose of midazolam). In the event of his aggression, it was important to maintain the safety of the staff who are administering treatment.

Dr Ma explained that when the alert occurred over the intercom, Dr Ma found Dungay unresponsive in a G Ward Cell. Originally, he thought that he might have aspirated on the biscuit and therefore began a resuscitation approach following the DRABCD method. He admits to checking the pulse and noticing that there was some food content and blood but not a major blockage. At this stage he chose to take part in chest compressions - of which he received training during basic life support in CPR on the 4th February 2015.

As a senior doctors and having additional training over the other staff (nurses) he undertook a leadership role in which he admits in hindsight he did not do efficiently, but at the time he did what was necessary. However, in his training he had only practiced on a mannequin as per certification - there was no training of assigning of roles managing for chaotic situations.


When asked if Dr Ma saw evidence of the chest rising and falling (to show the lungs between supplied with oxygen) he could recall being concerned about the adequacy of the air bag valve mask and claims that he attempted to correct his technique.

Dr Ma addressed that he interrupted chest compressions in order to address the fact that the thick vomit would not easily clear from the airway which meant he decided to put Dungay into the recovery position.

Following the Event

Dr Ma was questioned on his training in emergency response to which he confirmed that he had in the annual refresher of life support (which has not changed since the death of Dungay), and an advanced life support course in 2018.

Dr Ma was asked whether he was aware of changes at the Long Bay Hospital in regards to enforced medication and emergency sedation to which he is aware of a new collaborative effort between Justice Health and Custodial Services. Dr Ma also highlighted a reform in terminology: meetings called “safety huddles” are said to provide the staff with a better opportunity to assess risk and communicate delineation of roles in restraint and nursing.

Dr Ma admitted that he did not perform the resuscitation efficiently despite being employed as a Registrar. He also admits to the absence of an explanation regarding why Dungay’s aggression was deemed ‘high’ level (in respect to the staff’s observations).

Please see 'Report on Inquest 5 March 2019for a continued recount on this Coronial Inquest.




David Dungay Image




Expanding Berrima: women-only prison

More jails, more women in prison, more government failure
Media release NSW Greens: 23 July 2018

The NSW Greens claim that expanding Berrima prison by 500 beds and making it women only is an admission of failure from a Liberal National government addicted to a law and order auction.

The women in our prisons are overwhelmingly victims of abuse, crippled by financial distress and often self-medicating with drugs or alcohol. Nearly 40% are Aboriginal. These are women that are in the greatest need of help and support, instead the Coalition government’s response is to lock them up and throw away the key.

Greens MP and Justice Spokesperson David Shoebridge said in a statement on Monday:
‘Expanding Berrima and turning into a womens-only prison is an admission of failure from a government that has become addicted to police, jails and punishment.

The NSW Liberal National government has directly overseen a 50% increase in the number of women in jail. This is a national disgrace.

Aboriginal women are the fastest growing cohort, making up making up just 2.2 percent of population but 38% of the prison population.

Almost half of the women in prison haven’t even been found guilty. They are overwhelmingly single mothers, locked up on remand with a short stay in prison enough to tear their family apart.

Even when women have been found guilty it is overwhelmingly women who have committed non-violent offences, who are victims of abuse and come from a seriously disadvantaged background. These women need help not a jail cell.
The growing number of women in prison should be a wake up call to fix the system that puts them there in the first place, not to waste billions more on new and expanded prisons.

There is one simple solution to the overcrowding crisis in our prisons, it’s not building more jails, it’s to stop putting so many vulnerable people in jail in the first place.’

Mad in Australia

This publication exposes the history of abuse of mental health patients in historical and cultural context. It identifies how the culture of doctors forcing medication on mental health patients began, in breach of their ethical obligations, and against the evidence of its effectiveness. It also offers solutions.

Download the latest edition here.

Hong Kong Interns

Group photos with our 2018 interns from Hong Kong.
Meet Wing, Myra, Albee and Sky!






Justice Health Failure

Media Release: July 12, 2018

“The repeated failure of NSW Health to supply evidence justifying the forced injection of Malcolm Baker caused an adjournment of the case. The Mental Health Review Tribunal ordered them to provide us with the documents". A photo and full report of this latest news is available here.

“Two days before the hearing Justice Health psychiatrists forcibly injected him with double the previous dose of paliperidone. This was despite requests to await the decision of the Tribunal. Malcolm gave evidence of the medication’s side effects, included dribbling, difficulty in speaking, memory loss, dizzy spells, high temperature, increased anger, agitation and anxiety. He said it made him sick and asked to be left alone”.

“Malcolm is a non-violent prisoner who has not harmed anyone or himself during his twenty-six years of imprisonment. He had immediately taken responsibility for his actions after a fit of jealous rage 26 years ago”. See Malcolm's full profile here

“Two earlier hearings in February and April of 2018 had resulted in orders that lasted respectively 2 and 3 months. During each period, Mr Baker was relocated to Long Bay Prison to be forcibly injected. On neither occasion was it justified by anything he had done, but the orders were too short for a Supreme Court challenge. On three previous occasions in 2012, 2015 and 2016 the Tribunal refused to give Justice Health the order it asked for, after Justice Action defended him”.

“We presented to the Tribunal Malcolm’s Personal Management Plan which had been created by him and his family, as a positive alternative to the forced Treatment Plan. He asked to be held in a safe area, as well as have access to education and work”.

“This behavior by the Health Department is part of the same mental health culture exposed with Miriam Merten and described officially as ‘lacking compassion and humanity’. It is ongoing torture of an isolated elderly man, and we intend to stop it”.

Mad in Australia - November 2013

Mad in Australia Update November 2013

This publication exposes the history of abuse of mental health patients in historical and cultural context. It identifies how the culture of doctors forcing medication onmental health patients began, in breach of their ethical obligations, and against the evidence of its effectiveness. It also offers solutions. Click the link below to readthe latest edition.
You can also download the latest edition (Nov 6, 2013) here.

Read more

The Combined Churches Report

An inter-church committee reviewed and reinforced an earlier report by the Churches, called Prison: The Last Resort (1988). It called for a bipartisan approach to prison policy, provided it addresses the main issues. The committee recommended (7) that overcrowding be reduced and other conditions be addressed. It also called for (8) the immediate implementation of measures that reduce the numbers of Aboriginal people in prison as referred to by the Royal Commission into Aboriginal Deaths in Custody.

Inter Church Steering Committee on Prison Reform (1994) Prison - not yet the last resort: a review of the NSW penal system.

Failed Health Department Plan - Media 160518

Abuse in mental health normal

Media release Wednesday May 16, 2018
The callous disrespect exposed in Lismore Hospital to dying Miriam Merten will continue. Nothing in Health’s Implementation Plan will change the culture. There will be no ongoing objective accountability, no removal of legislative protections such as s.195 MH Act, no computers and phones in seclusion areas, no alternatives to forced treatment, and no independent consumer advocacy. The timetable shows no urgency for consumers getting on Committees and no structure for electing representatives. The endemic corruption of mental health, with noses in the NSW Health Department’s annual trough of $23 billion is disgraceful to all those who don’t demand structural changes after such an exposure.

The Review by the Chief Psychiatrist made very serious criticisms of the NSW Mental Health System. It said that the NSW Mental Health culture lacked compassion and humanity (p7) or real interest in the individual beyond risk management (p22). The System used coercive compliance, had no internal oversight even after the Merten death (p29), lacked guidelines, had little evidence of engagement with consumers and carers (p35), little involvement in care plans (p.36), had no examples of the necessary leadership required to give high-quality compassionate care (p24). The Review said that peer worker support was very limited with rare access despite being a vital resource to lessen seclusion and restraint (p33). It requires urgent action.

The case of Saeed Dezfouli shows that abuse of power is endemic to mental health, regarding the disabled as easy targets without rights. Locked in the Forensic Hospital Saeed has been refused access to a computer or legal information even though he has to argue for his freedom against the barristers of the Attorney General and Justice Health on a difficult point of law. The Medical Superintendent Dr Ellis stated that Saeed could handwrite his Submissions, would have no more than two hours a week with a computer, could borrow necessary books from public libraries, and would have no more than 30 minutes a week to access the internet, with a staff member using the mouse and keyboard. As a prisoner, he would get a computer and information.

Saeed’s case has international interest, where due process and the Rule of Law must be maintained. Justice Health submitted to the Mental Tribunal its concern about further criticism of Australia from the UN Committee of the Rights of Persons with Disabilities, with continuing media attention. It said that Saeed is costing them too much money and causing staff to be frustrated because he isn’t submissive despite being forcibly medicated. He and Miriam are examples of thousands of others where Health has lost its obligation to be person centred. It needs external and consumer monitoring as effective as the CCTV and media exposure for Miriam.


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