The Dungay family gathered in the witness box this afternoon, the last to speak at the long inquest into the death of the Dunghutti man, who died after guards rushed his cell and restrained him face down on the floor in Long Bay jail hospital in 2015.

David’s mother Leetona, supported by her children, spoke powerfully about David’s childhood, managing his diabetes as his “nurse and diabetes educator” from a very young age, and how she watched him “grow into a lovely young man”.

“He made bad mistakes but he did his time and paid his debt. He was so close to being free.”

Leetona said she asked the court to deliver justice for her family.

“I have nothing against you lawyers in the expensive suits who went to good schools. You worked hard to get where you are. But face facts – you have no idea what it is to grow up as an Aboriginal person in this country.

“Imagine a game of footy like David used to play, but one team has to play with one hand tied behind their back. That’s what racism and discrimination feels like for us.”

“No mother should ever have to feel the pain of burying a son and watching him die begging to breathe. The whole world has seen the footage of David begging for his life and saying he can’t breathe, to his last gasp.

“One minute my beautiful son was alive and healthy, the next he was dead.”

“I’m looking at all you men and women in the courtroom and asking you for someone to be held accountable for my son’s homicide.”

The deputy coroner Derek Lee was visibly moved.

“Thank you for sharing those words,” Lee said.

“You have heard hours of evidence and gone through thousands of pages but the words said today are just as important.

“Thank you for giving us a picture of David that has nothing to do with jails and psychiatrists and handcuffs. I can’t imagine how difficult it must be for you, and we thank you for sharing those memories of David with us.”

Coroner Lee adjourned the inquest and will give his findings on August 23.

Earlier, New South Wales Corrections apologised to the family of David Dungay, admitting it was “critical to acknowledge the organisational failures that occurred” in the lead up to his death.

Dungay, a diabetic, died after guards rushed his cell to stop him eating a packet of biscuits, and then transferred him to another cell, restrained him face down on the floor and injected him with a sedative.

During the ordeal, Dungay said 12 times he couldn’t breathe, before going into cardiac arrest and dying.

NSW assistant commissioner of custodial corrections, Kevin Corcoran issued the apology at the beginning of the final day of the inquest, which began last year but ran behind schedule, and resumed for a final week on Monday.

“I offer sincere condolences to Mr Dungay’s family,” Corcoran said. “It has caused pain, a pain that will continue well into the future, and for this I apologise.

Custodial services did not train its officers in risk factors for positional asphyxia, Corcoran said, nor to “fully exhaust the de-escalation procedures.”

“These are organisational failures and do not reflect the actions of the corrective officers involved,” he said.

On Thursday, two expert witnesses told the court that Dungay most likely died from an exacerbation of pre-existing heart problems while being restrained.



Professor Mark Adams, a cardiologist from Swinburne University, said under questioning on Thursday that Dungay’s psychiatric medication, his diabetes, and other health factors could have triggered an irreversible heart attack.

Adams also explained that when Dungay was telling guards he could not breathe, he was most likely experiencing a heart arrhythmia, which led to a type of fast heart rate caused by improper electrical activity in the heart, which ultimately led to death.



“Shortness of breath could be a symptom,” he said.



Kendall Bailey, the forensic pathologist who conducted the post-mortem, agreed that Dungay died from some form of cardiac arrhythmia, but said she could not scientifically demonstrate a single cause of death, because there were too many factors at play.

“I do not doubt that the mechanism of death is a cardiac arrhythmia, but I can’t tell you what the reason for the arrhythmia is.”

“It’s unascertained, because there are far too many contributing factors and confounding things that could point to the cause of death,” she said.

John Farrar, a toxicologist from the Sydney Forensic Medicine and Science Network, cast doubt on the role that the sedative midazolam played in Dungay’s death.



“Midazolam injected by intramuscular means would not have had an effect so soon after injection,” he said.

Earlier in the week, the court heard that Dungay did not need to be moved to another cell because there was no medical emergency.

Dr Trevor Ma, who was the psychiatric registrar on duty at the time of Dungay’s death in custody, said on Tuesday there could have been more attempts to de-escalate the situation before guards rushed Dungay’s cell, restrained him, and injected him with a sedative.