A coroner has criticised Northern Territory authorities for not telling the family of an Indigenous man in custody that he was critically ill until after he died, 12 days after being admitted to hospital.

Kwementyaye Japaljarri*, 34, was serving a five-month prison sentence for non-violent driving-related offences. He had a long history of illness and the coroner, Greg Cavanagh, said his medical care was adequate.

However Cavanagh took aim at NT Correctional Services for not telling Japaljarri’s family he was ill, preventing them from being with him during the almost two weeks between hospitalisation and death.

“There are obviously good security reasons why a family might not be notified of a prisoner being outside the prison,” Cavanagh said.

“However, where the prisoner is in a serious condition, common sense and ordinary human compassion suggest that for the sake of the family and the prisoner, the family need to be notified.”

He said it would have been better for both Japaljarri and his family if they were able to be with him in hospital.

Speaking on behalf of the family, Robyn Patton had told the coronial inquiry she didn’t know Japaljarri had died until she saw people wailing and walking to “sorry camp”, and asked them why.



She and his family were shocked at the news of his death, and that they had not been told, she said.

“We were all asking: what happened to him in prison? We had no idea that he had been in hospital. We had no idea why or how he had passed away … I am upset that family was not told that he had been admitted to hospital,” Patton said.

“Had family known that he was in hospital, we might have been able to reach out to him, and his family in Darwin, the Rose family and maybe some Jigili family, might have been able to visit him before he passed away. It makes me very sad that he wasn’t with any family when he passed away or hadn’t seen any family in hospital.”

Japaljarri was arrested in October 2016, convicted and imprisoned for the 22nd time in his life – primarily for driving under the influence while disqualified. He was due for release in March 2017.

However his health deteriorated while at the prison and he was taken to Darwin hospital on 3 December 2016. He died 12 days after admission.

The coroner described his medical conditions as “most complicated”, and said while elements of his treatment could have been done better, it would not have saved his life.

Darwin hospital staff also conceded they did not have adequate interpreter services for Japaljarri.

Japaljarri had a long history of ill health, believed to be related to an autoimmune disease, and was frequently treated at Katherine hospital. However there was no system in place to inform Katherine Hospital that Japaljarri had been jailed.

Cavanagh noted this would have made little difference to the outcome of Japaljarri’s illness but the prison may have been better informed. A new program beginning in 2018 should solve these issues, he said.

The territory’s corrections commissioner, Mark Payne, indicated to the coroner he would see that a requirement was added to standard operating procedures that family be told when a critically ill or dying prisoner was taken to hospital.

All NT deaths in custody are automatically referred to the coroner. The royal commission into the vast overrepresentation of Indigenous people among deaths in custody, which was held 25 years ago, returned more than 330 recommendations to reduce the rate.

The incarceration rate has instead steadily increased since then, and there is widespread criticism of laws that overwhelmingly result in Indigenous people being incarcerated for non-violent crimes, such as non-payment of fines and driving offences, and mandatory sentences.

*The use of the forename Kwementyaye is in keeping with Indigenous cultural customs for naming deceased persons