The Indigenous man’s death in Long Bay jail after a disagreement about a packet of biscuits has raised questions about the use of medical restraint and tranquillisers

'If you can talk, you can breathe': the death in custody of David Dungay

'If you can talk, you can breathe': the death in custody of David Dungay

On a December morning in 2015, David Dungay started eating a packet of Tim Tams inside his cell at Sydney’s Long Bay jail. He was told to stop but refused, and the situation escalated. By the time it was over, Dungay was dead.

When the 26-year-old Dunghutti man refused to stop eating the biscuits, corrective services staff called the Immediate Action Team, which specialises in cell extractions. Dungay was given two minutes to comply with the order before the IAT rushed his cell, manoeuvred him face-down on to his mattress and handcuffed him behind his back.

Dungay told officers he couldn’t breathe, to which one responded: “If you can talk, you can breathe.”

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He was picked up, moved to another cell and held face-down again. Officers positioned themselves on top of him, pulling down his green prison uniform pants and calling for a nurse, who injected 10 milligrams of the sedative midazolam. Then they retreated to the doorway.

Moments later, Dungay stopped breathing.

Staff from the mental health unit and paramedics tried to resuscitate Dungay for almost an hour, but his death was declared at 3.42pm.

Dungay’s death is subject to an inquest scheduled for July. The initial autopsy report was unable to determine the cause of death, but found a series of “abnormalities” could have contributed to it.

The autopsy found evidence that compression of Dungay’s torso and neck while he was held down could have contributed to asphyxia, which “may result in hypoxia and/or cardiac arrest”.

The report also noted the short time between the midazolam injection and Dungay’s death, but because intramuscular injections typically have a slow onset, it “may have been unlikely to have had a significant effect”. Further expert assessment was recommended.

It didn’t even look like my son’s body. His face was caved in, bruises all around Leetona Dungay

At least one other death in custody has been directly attributed to the combination of midazolam and restraint, and two others associated with it. There are many more individually attributed to prone physical restraint or to midazolam used during a chemical restraint procedure.

Guardian Australia has spoken to a dozen experts and medical practitioners about the circumstances of Dungay’s death. Many said the combination of prone physical restraint and chemical restraint carried a life-threatening risk if not done properly.

Police said Dungay’s death was not suspicious and a corrective services investigation found no criminal negligence, but his family and supporters have continued to protest.

“It didn’t even look like my son’s body. His face was caved in, bruises all around, stitches here and there,” says his mother, Leetona Dungay.

“I had a feeling then, I knew that over-aggressive force was used on my son by the correctional services officers.”

Facebook Twitter Pinterest Leetona Dungay, the mother of David Dungay, calls for justice outside the NSW coroners court in Sydney. Photograph: David Moir/AAP

Dungay grew up in Kempsey on New South Wales’s mid-north coast. His mother has fond memories of his younger years, especially his love of rugby league.

His sister Christine Dungay remembers her younger brother falling in with the wrong crowd. He was in and out of juvenile homes for a while, she tells Guardian Australia, but mostly kept out of trouble until he was arrested and convicted of assault, aggravated attempted sexual intercourse and party to robbery in 2009.

From a young age diabetes played a defining role in Dungay’s life. When his blood sugar levels spiked his behaviour changed radically, Leetona says. “That’s why I think they diagnosed him with schizophrenia.”

Dungay was admitted to the mental health unit after suffering psychosis a month before his death.

According to a Justice Health report obtained by Guardian Australia, the unit’s staff documented perceptual disturbances, aggressive behaviour and a number of violent episodes – the last of which culminated in the confrontation that ended his life.



Members of Dungay’s immediate family have watched the footage of his death as part of a review of evidence submitted to the inquest. His mother still has nightmares.

“I have flashes that I’m trying to fight back for my son,” she says.

Facebook Twitter Pinterest Friends and relatives of David Dungay rally outside Long Bay jail. Photograph: Brendan Esposito/AAP

Dr Hugh Grantham, professor of paramedics at Flinders University, says midazolam’s common side effects may be exacerbated by prone physical restraint.

“The key element is planning – ensuring that there are adequate numbers of experienced personnel supported by appropriate monitoring and emergency equipment,” he says.

If the people carrying out the procedure aren’t adequately trained, or don’t have the right equipment, backup or support, “then that could be a potentially difficult and dangerous situation”.

Other experts variously described the combination as a “potentially dangerous situation” and “scientifically consistent with being able to kill someone”.

The Justice Health investigation found staff involved in Dungay’s death “had not been involved in prior emergency response incidents and have very little primary healthcare experience”.

It also found discrepancies in understanding among staff on “what nursing staff should do following the administration of enforced medication”, with an unclear demarcation of responsibility between them and corrections staff.

According to the report, the nurses attending Dungay’s restraint said they “did not feel safe going back into the cell despite the IAT presence and the patient stating that he could not breathe”.

An addendum said the department would “review and amend facility policy as necessary to clearly communicate what the staff roles and responsibilities are”.

Justice Health has since detailed multiple training programs for staff since 2016, including in responding to and coordinating care during an emergency response, and training all nurses to take on the role of “team leader” during an emergency.

“Emergency response simulation and team leader training is ongoing for all staff in Long Bay Hospital,” a spokeswoman said.

“In addition, all clinical staff in the Hospital undergo annual mandatory training in Basic Life Support and Cardiopulmonary Resuscitation (CPR).”

Justice Health implemented training for medical officers in “emergency sedation, seclusion and restraint” this year, and is currently reviewing its policy on medications used in emergency sedation.



Although midazolam is safely used in various settings, experts say monitoring a patient’s airways after the administration of the drug is crucial because one of the most common effects is to slow – or stop – breathing.

Current Justice Health guidelines, last updated in 2016, simultaneously tell medical staff to remove themselves from the vicinity – which the nurses involved in Dungay’s restraint did – and to continue monitoring the patient’s health and airways.

A medical emergency response team, trained to deal with incidents such as Dungay’s, was disbanded some years before his death. Investigators were “unable to ascertain” why.

Facebook Twitter Pinterest A relative of David Dungay protests outside Long Bay jail, where Dungay died in December 2015. Photograph: Brendan Esposito/AAP

Dr Peg LeVine, an associate professor of psychiatry at Monash Health, says recommending changes to department policy is not enough.

“If indeed a nurse was instructed to inject 10mg of midazolam to a man positioned on his stomach with officers sitting on him, and knew there was no way to monitor their patient and they complied, then all medical people in attendance of this behaviour are reportable to [the Australian Health Practitioner Regulation Agency] and it requires an investigation.”

Guidelines for the safe use of chemical and physical restraint vary between states and institutional sectors.

After the death in custody of William Wallace in 2008, South Australian paramedics were given new guidelines recommending the prevention of the combined use of midazolam and prone physical restraint.

Months before Dungay’s death NSW emergency departments changed their preferred sedative for rapid tranquilisation (the term for the procedure used on Dungay) to droperidol in response to feedback from frontline staff.

NSW health department guidelines state that patients should not be held in a prone position for more than two to three minutes, and emergency room guidelines for rapid tranquilisation procedures recommend the team leader closely monitors the patient’s airway and physical condition.

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Professor Bernadette McSherry, who is conducting a review of restraint legislation, says there is a lack of nationally agreed definitions of restraint, and of monitoring in corrections facilities.

“Traditionally we don’t have any mechanism for independent oversight of what actually happens in these places,” she says. “Unfortunately, people don’t know that [restraint] occurs. And I think it’s only when you have a death … that this gets highlighted.”

At least one other person, Shaun Coolwell, has died after being physically restrained and administered midazolam.

Paramedics and police responded to an incident at his sister’s residence on the outskirts of Brisbane. Coolwell was held in the prone position and administered midazolam after an altercation with police. He later died in Logan hospital. The coroner has yet to report his findings after an inquest in March into Coolwell’s death.

In 2010, Lyji Vaggs, an Indigenous man from Townsville, died in custody after being physically restrained and administered midazolam as well as an antipsychotic.

The coroner’s report, as in Dungay’s case, noted the short period between midazolam being administered and Vaggs showing signs of distress.

“A short time after the midazolam was administered – witnesses variously estimate the period to be two to five or six minutes – Mr Vaggs suddenly stopped struggling, calling out and breathing,” it said.

Most experts called during the inquest agreed the drug played some role in Vaggs’s death, although there was some disagreement about the extent. The coroner ruled Vaggs’s death was “a result of the combined effects of the drugs administered to him and the length and nature of the restraint to which he was subject”.

In 2008, William Wallace died in custody in circumstances that also involved the combination of midazolam and restraint.

But the coroner found “whilst connection between the administration of midazolam and Mr Wallace’s collapse is a standout feature of the circumstances, it is simply impossible to say that on a balance of probabilities it had made any contribution at all”.



Coolwell, Vaggs and Dungay were all Indigenous men and Vaggs and Dungay had also been diagnosed with schizophrenia.

“An Aboriginal-identified person is vulnerable enough in our western-centric culture,” LeVine says. “One’s social status is reduced even more by being labelled as socially deviant or mentally ill. All those social statuses make them more vulnerable to trauma experiences – and in the case of medical restraint, they have no say in those decisions that lead to more trauma or death.”

The screws that did it are still working, they have to get charged with something – they took my brother’s life Ernie Dungay

Corrective Services NSW said deeply regretted Dungay’s death and extended its deepest sympathies to the family. A spokeswoman said the organisation fully supported the coronial inquiry.

“The investigation report into Mr Dungay’s death resulted in many changes to policy and training procedures,” she said.

“Serious consideration will be given to any coronial recommendations addressed to the Commissioner of Corrective Services NSW.”

The Dungay family hopes the inquest will get to the bottom of David’s death, but they say correctional services and Justice Health should be held accountable for what happened.



“What correctional services and the medical staff are doing, they’re trying to sweep it under the rug and make it out like they did nothing wrong – when we know they did something wrong,” says Ernie Dungay, David’s older brother.



“The screws that did it are still working, they have to get charged with something – they took my brother’s life.



“All I want is justice for my little brother, so we can put his soul to rest.”

The coronial inquiry into Dungay’s death is scheduled to take place on 16 July.



